NURSING DIAGNOSIS: Breastfeeding, ineffective, related to lack of exposure, misconceptions, or knowledge deficit as evidenced by first baby, mother’s verbalization, or nursing observations
Outcome Identification and Evaluation
Mother/infant dyad will experience successful breastfeeding: infant will latch on, suck and swallow at the breast; mother will not experience sore nipples.
Interventions: Promoting Effective Breastfeeding
• Educate mother on recognition of and response to infant hunger cues to promote on-cue breastfeed- ing, which will establish milk supply.
• Educate mother on appropriate diet and fluid intake to ensure ability to manufacture adequate supply of breast milk.
• Demonstrate breastfeeding positions with infant at the breast (appropriate positioning increases probability of successful latch).
• Assess infant’s latch technique, sucking motion, and audible swallowing (an appropriately latched infant will take most of the areola in the mouth,
suck in spurts, and demonstrate audible swallowing).
• Assess infant voiding/stool patterns: at least six voids per day and passage of stool ranging from one or more per day to one every several days is a normal pattern for breastfed infants.
• Assess infant weight gain: gain of 15 to 30 g per day after the second week of life indicates infant is receiving appropriate nutrition.
• Assess mother’s nipples for redness or soreness;
if infant appropriately latches on, nipples will not become sore.
NURSING DIAGNOSIS: Risk for altered growth pattern (risk factors: caregiver knowledge deficit, first infant, premature infant, or maladaptive feeding behaviors)
Outcome Identification and Evaluation
Infant will demonstrate adequate growth and appropriate feeding behaviors: steady increases in weight, length, and head circumference; infant feeds appropriately for age.
Interventions: Promoting Adequate Growth
• Observe mother/infant dyad breastfeeding or bottle-feeding to determine need for further education or identify infant difficulties with feeding.
• Educate mother about appropriate breastfeeding or bottle-feeding so that mother is aware of what to expect in normal feeding pattern.
• When infant is old enough, provide education about addition of solid foods, spoon and cup feeding: after 6 months of age breast milk or formula needs to be supplemented with a variety of foods.
• Determine need for additional caloric intake if necessary (premature infants and infants with chronic illnesses or metabolic disorders often need adjustments in caloric intake to demonstrate adequate or catch-up growth).
• Obtain daily weights if hospitalized (weekly if outpatient) and weekly length and head circumference to determine whether feeding pattern is sufficient to promote adequate growth.
NURSING CARE PLAN 25.1
C h a p t e r 2 5 Growth and Development of the Newborn and Infant 905
Growth and Development Issues in the Newborn and Infant
(continued)NURSING DIAGNOSIS: Nutrition, altered, less than body requirements, related to possible ineffec- tive feeding pattern or inadequate caloric intake as evidenced by failure to gain weight or by inadequate increases in weight, length, and head circumference over time
Outcome Identification and Evaluation
Infant will take in adequate nutrients using effective feeding pattern: infant will demonstrate ade- quate weight gain (15 to 30 g per day) and steady increases in length and head circumference.
Interventions: Promoting Adequate Nutritional Intake
• Assess current feeding pattern and daily intake to determine areas of concern.
• Increase frequency of breastfeeding or volume of bottle-feeding if needed to meet caloric needs.
• Introduce solid foods on age-appropriate schedule:
introducing solids at the right time improves the chances that the child will learn to take solid foods.
• Limit juice intake or discontinue altogether (juice has little nutritive value and displaces nutrients from breast milk or formula).
• Use human milk fortifier (if ordered) to increase caloric density of breast milk.
• Increase caloric density of formula (if ordered) by mixing to a more concentrated level or with additives (fats or carbohydrates) to provide increased calories needed to support adequate growth.
• If infant is taking solids already, choose higher-calorie foods to maximize nutrient intake.
NURSING DIAGNOSIS: Parent/infant attachment, altered, risk for (risk factors: premature infant, parental knowledge deficit about normal newborn activity and care, infant with difficult tempera- ment or medical problems)
Outcome Identification and Evaluation
Parent and infant will demonstrate appropriate attachment via eye contact, parental response to infant cues, parental verbalization of caring for infant, infant response to parent’s caretaking behaviors.
Interventions: Encouraging Appropriate Parent–Infant Attachment
• Assess parent’s response to infant cues to determine degree of attachment and level of parent’s knowledge about infant care.
• Assess infant’s response to parent’s caretaking behaviors to determine degree of attachment.
• Determine infant’s temperament to counsel parent effectively about responses appropriate for that type of temperament.
• Encourage en face positioning for holding or feeding the young infant to encourage give-and-take response between infant and parent.
• Encourage parent to meet infant’s needs promptly and with affection to promote sense of trust in the infant.
• Reinforce parent’s attempts at improving attachment with infant (positive reinforcement naturally encourages appropriate behaviors).
(continued)
NURSING CARE PLAN 25.1
906 U N I T 9 Health Promotion of the Growing Child and Family
Growth and Development Issues in the Newborn and Infant
(continued)NURSING DIAGNOSIS: Growth and development, altered, related to speech, motor, psychosocial, or cognitive concerns as evidenced by delay in meeting expected milestones
Outcome Identification and Evaluation
Development will be maximized: infant will make continued progress toward attainment of developmental milestones.
Interventions: Maximizing Development
• Perform developmental evaluation of the infant to determine infant’s current level of functioning.
• Offer age-appropriate play, activities, and toys to encourage further development.
• Carry out interventions as prescribed by develop- mental specialist, physical therapist, occupational therapist, or speech therapist (repeated exposure to
the activities or exercises is needed to make develop- mental progress).
• Provide support to parents of infants with develop- mental concerns, as developmental progress can be slow and it is difficult for families to stay moti- vated and maintain hope.
NURSING DIAGNOSIS: Caregiver role strain, risk for (risk factors: first baby, knowledge deficit about infant care, lack of prior exposure, fatigue if premature, ill, or developmentally delayed infant)
NURSING DIAGNOSIS: Injury, risk for (risk factors: developmental age, infant curiosity, rapidly progressing motor abilities)
Outcome Identification and Evaluation
Parent will experience competence in role: will demonstrate appropriate caretaking behaviors and verbalize comfort in new role.
Interventions: Preventing Caregiver Role Strain
• Assess parent’s knowledge of newborn/infant care and the issues that arise as a part of normal development to determine parent’s needs.
• Provide education on normal newborn/infant care so that parents have the knowledge they need to appropriately care for their new baby.
• Provide anticipatory guidance related to normal infant development to prepare parents for what to expect next and how to intervene.
• Encourage respite for parents (even a few hours away from the demands of an infant’s care can rejuvenate the parents).
Outcome Identification and Evaluation
Infant safety will be maintained: infant will remain free from injury.
Interventions: Preventing Injury
• Encourage car seat safety to decrease risk of injury related to motor vehicles.
• Childproof home: as infant becomes more mobile, he or she will want to explore everything, increasing risk of injury.
NURSING CARE PLAN 25.1
C h a p t e r 2 5 Growth and Development of the Newborn and Infant 907
Promoting Early Learning
Research has shown that reading aloud and sharing books during early infancy are critical to the develop- ment of neural networks that are important in the later tasks of reading and word recognition. Reading books increases listening comprehension. Infants demonstrate their excitement about picture books by kicking and waving their arms and babbling when looking at them.
At 6 to 12 months, the infant reaches for books and brings them to the mouth. Over time, reading leads to acquisition of language skills. Reading picture books and simple stories to infants starts a good habit that should be continued throughout childhood (Zuckerman, 2009).
Promoting Safety
Hundreds of children younger than 1 year of age die each year as a result of injury (AAP, 2012d). As infants become more mobile, they risk injury from falls down stairs and off chairs, tables, and other structures. Curiosity leads the infant to explore potentially dangerous items, such as electrical outlets, hot stove or furnace vents, mop buckets, and toilets. Since infants explore so much with their mouths, small objects or hard foods pose a choking hazard. The infant will invariably pick up any accessible object and bring it to the mouth. With increasing dex- terity, poisoning from medications, household cleaning products, or other substances also becomes a problem.
Safety in the Car
Motor vehicle accidents are one source of injury, par- ticularly if the infant is improperly restrained. Infants should never be transported in a motor vehicle without proper restraint. Infant car seats should face the rear of the car until the infant is 12 months of age and weighs 20 pounds (AAP, 2012b). The car seat should be secured tightly in the center of the back seat. The infant should
Promoting Growth and Development Through Play
Experts in child development and behavior have said repeatedly that play is the work of children. Infants practice their gross and fine motor skills and language through play (Goldson & Reynolds, 2011). Play is a natu- ral way for infants and children to learn. Play is critical to infant development, as it gives infants the opportu- nity to explore their environment, practice new skills, and solve problems. The newborn prefers interacting with the parent to toys. Parents can talk to and sing to their newborns while participating in the daily activities that infants need, such as feeding, bathing, and chang- ing diapers. Newborns and young infants love to watch people’s faces and often appear to mimic the expres- sions they see.
As infants become older, toys may be geared toward the motor skills or language skills that the child is devel- oping. Parents can promote fine motor development in infants by providing age-appropriate toys. For example, a rattle that a young infant can hold promotes reaching and attaining. The older infant builds fine motor skills by stacking cups or placing smaller toys inside of larger ones. Gross motor skills are reinforced and practiced over and over again when the infant wants to reach something he or she is interested in.
When playing with toys, the infant usually engages in solitary play; he or she does not share with other in- fants or directly play with other infants (Feigelman, 2011;
Goldson & Reynolds, 2011). A wide variety of toys are available for infants, but infants often enjoy the most ba- sic ones, such as plastic containers of various shapes and sizes, soft balls, and wooden or plastic spoons.
Books are also very important toys for infants. Read- ing to all ages of infants is appropriate, and the older infant develops fine motor skills by learning to turn book pages.
Table 25.6 lists age-appropriate toys.
Growth and Development Issues in the Newborn and Infant
(continued)• Parents should have the Poison Control Center phone number available: should an accidental ingestion occur, Poison Control can give parents the best advice for appropriate intervention.
• Never leave an infant unattended in the sink, bathtub, or swimming pool to prevent drowning.
• Teach parents first aid measures and infant CPR to minimize consequences of injury should it occur.
• Parents should watch the infant at all times (no amount of childproofing can replace the watchful eye of a caring parent).
NURSING CARE PLAN 25.1
908 U N I T 9 Health Promotion of the Growing Child and Family
safety can be found on at http://thepoint.lww .com/ricci-kyle2e.
Even before the infant can roll over, he or she wig- gles and pushes with the feet. The infant can easily fall from a changing table, sofa, or crib with the side rails down, so the infant should never be left unattended on any surface. If infant seats, bouncy seats, or swings are used, the infant should always be restrained in the seat with the appropriate straps.
The AAP (2012c) does not recommend the use of infant walkers, because the walker may tip over and the baby may fall out of it or the infant may fall down the stairs in it. Walkers allow infants access to things they may not otherwise be capable of reaching until they are able to walk alone, such as hot stoves and items on the edge of the countertop.
As the infant becomes more mobile, learning to crawl and walk, new safety issues arise. Safety gates should be used at the tops and bottoms of stairways.
Gates may also be used to block curious infants from rooms that may pose physical danger to them because of sharp-edged furniture or decorative objects. Electrical never be placed in a front seat that is equipped with an
airbag.
Infants should never be left unattended in a motor vehicle. The temperature rises very quickly inside a closed vehicle, and an infant can suffocate from heat in a closed vehicle in the summer. Even during cooler weather, the heat generated within a closed vehicle can reach three to five times the exterior temperature. Kidnapping is also a concern if the baby is left unattended in a vehicle. Addi- tional information on car safety can be found on at http://thepoint.lww.com/ricci-kyle2e.
Safety in the Home
The baby’s crib should have a firm mattress that fits snugly in the crib on a secure support. The distance be- tween crib slats should be 2 3/8 inches or less to prevent injury (Safe Kids Worldwide, 2009). All crib edges should be smooth. Only well-fitting crib sheets should be used, not sheets intended for large beds. Crib side rails should always be raised when the parent is not right next to the crib. Additional information about crib and playpen
TABLE 25.6 APPROPRIATE TOYS FOR NEWBORNS AND INFANTS
Age Appropriate Toys
Newborn to • Mobile with contrasting colors or patterns 1 month • Unbreakable mirror
• Soft music via tape or music box
• Soft, brightly colored toys 1 to 4 months • Bright mobile
• Unbreakable mirror
• Rattles
• Singing by parent or caregiver, varied music
• High-contrast patterns in books or images 4 to 7 months • Fabric or board books
• Different types of music
• Easy-to-hold toys that do things or make noise (fancy rattles)
• Floating, squirting bath toys
• Soft dolls or animals 8 to 12 months • Plastic cups, bowls, buckets
• Unbreakable mirror
• Large building blocks
• Stacking toys
• Busy boxes (with buttons or knobs that make things happen)
• Balls
• Dolls
• Board books with large pictures
• Toy telephone
• Push–pull toys (older infants)
Adapted from Schuman, A. T. (2007). The ABCs of toy safety: More than just child’s play. Contemporary Pediatrics, 24(7), 49–57, 64; and Shelov, S. P., & Altmann, T. R. (Eds.). (2009). Caring for your baby and young child: Birth to age 5 (5th ed.). New York: Bantam Books.
C h a p t e r 2 5 Growth and Development of the Newborn and Infant 909 AAP recommends that parents use caution when en- rolling their infant in an aquatic or swim program.
Research has not sufficiently demonstrated that wa- ter survival skills taught to infants are effective (AAP, 2010). Completing an aquatic program does not de- crease the risk of drowning; vigilant supervision is still always required.
Promoting Nutrition
Adequate nutrition is essential for growth and develop- ment. Breastfeeding and bottle-feeding of infant formula are both acceptable means of nutrition in the newborn and infant. Breast milk or formula supplies all of the in- fant’s daily nutritional requirements until 4 to 6 months of age, at which time solid foods may be introduced (Shelov & Altmann, 2009).
Cultural Factors
Many dietary practices are affected by culture, both in the types of food eaten and in the approach to progression of infant feeding. Some ethnic groups tend to be lac- tose intolerant (particularly blacks, Native Americans, and Asians); therefore, alternative sources of calcium must be offered. Explore the cultural practices of the family re- lated to infant feeding so that you can support the fam- ily’s cultural values.
Nutritional Needs
Newborns and infants are experiencing tremendous growth and need diets that support these rapid changes.
Table 25.7 compares fluid and caloric needs in the new- born and infant.
outlets should be covered with approved safety covers.
Cabinets and drawers should be secured with child safety latches. Medications, household cleaning supplies, and other potentially hazardous substances should be stored completely out of reach of infants (AAP, 2012d).
Choking is a risk because infants immediately bring small items to the mouth for exploration. To avoid chok- ing, recommend the following to parents:
• Use only toys recommended for children 0 to 12 months of age.
• Avoid stuffed animals with eyes or buttons that can be dislodged by the persistent infant.
• Keep the floor free of small items (accidentally dropped coins, paper clips, straight pins).
• Avoid feeding popcorn, nuts, carrot slices, grapes, and hot dog pieces to infants.
Suffocation is also a risk for infants. Cribs should not have pillows, comforters, stuffed animals, or other soft items in them. Keep plastic bags of any size away from infants. Avoid the risk of strangulation by keeping window blind and drapery cords out of the infant’s reach (AAP, 2012c, 2012d).
Though no safety measure is as effective as close supervision by a watchful parent or caregiver, the afore- mentioned safety measures can be critical to the infant’s well-being.
Safety in the Water
Infants can drown in a very small amount of water.
Never leave an infant unattended in the sink, a baby bathtub or standard bathtub, a swimming or wading pool, or any other body of water, even if it is quite shallow. The bathroom door should be kept closed and the toilet lid down. Water should be emptied from tubs, pails, or buckets immediately after use. If the family has a swimming pool, a locked fence or locked screen enclosure should surround it. Exterior doors should be kept locked to prevent the older infant from wandering out to the pool (AAP, 2012d). The
TABLE 25.7 NUTRITIONAL REQUIREMENTS Nutritional
Requirements Newborn Infant
Fluid 140–160 mL/kg/day 100 mL/kg/day for first 10 kg 50 mL/kg/day for next 10 kg Calories 105–108 kcal/kg/day 1 to 6 months: 108 kcal/kg
6 to 12 months: 98 kcal/kg
Adapted from Johns Hopkins Hospital, Arcara, K., & Tschudy, M. (2012). The Harriet Lane handbook (19th ed.). St. Louis, MO: Mosby.
Remember Allison Johnson, the infant described in the beginning of the chapter? What anticipatory guidance related to safety would you provide to Allison’s parents?
910 U N I T 9 Health Promotion of the Growing Child and Family
may hold the breast in a “C” position if that is helpful to her. Stroke the nipple against the baby’s cheek (Fig. 25.9).
This should stimulate the infant to open the mouth widely.
Bring the baby’s wide-open mouth to the breast to form a seal around all of the nipple and areola (Fig. 25.10). When the infant is finished feeding, the mother can break the suction by inserting her finger into the baby’s mouth, thus releasing the mouth from the nipple (Fig. 25.11). This tech- nique may prevent the infant from pulling on the nipple, which can lead to soreness and cracking.
Watching and listening to the infant feed may assess the adequacy of the baby’s latch technique. The infant who is properly latched on to the breast will suck rhyth- mically, taking most or all of the areola into the mouth.
Audible swallowing should be heard as milk is deliv- ered into the infant’s mouth. Assess the mother for pain
Breastfeeding
The NAPNAP, the AAP, the American College of Obstet- rics and Gynecology, the American Dietetic Association, and the U.S. Breastfeeding Committee of the Department of Health and Human Services all recommend breast- feeding as the natural and preferred method of newborn and infant feeding (NAPNAP, 2007). In their position statement on breastfeeding (2007), NAPNAP identifies
“human milk as superior to all substitute feeding meth- ods.” Breast milk provides complete infant nutrition.
Breastfeeding or feeding of expressed human milk is recommended for all infants, including sick or prema- ture newborns (with rare exceptions). The exceptions include infants with galactosemia, maternal use of illicit drugs and a few prescription medications, maternal un- treated active tuberculosis, and maternal HIV infection in developed countries.
Data from the Centers for Disease Control and Prevention’s (CDC) Breastfeeding Report Card – United States, 2010 indicate that in 2010 75% of US women breastfed in the early postpartum period, 43% of infants were breastfeeding at 6 months of age, and only 22.4%
were still breastfeeding at 1 year of age (CDC, 2010).
Even partial breastfeeding is helpful and offers some of the health benefits of breastfeeding. Pediatric nurses in the community and the hospital are in an excellent posi- tion to promote and support breastfeeding.
BREAST MILK COMPOSITION
Breast milk includes lactose, lipids, polyunsaturated fatty acids, and amino acids. The ratio of whey to casein protein in breast milk makes it readily digestible. The high concen- tration of fats and the balance of amino acids are believed to contribute to proper myelination of the nervous system.
The concentration of iron in breast milk is less than that of formula, but the iron has increased bioavailability and is sufficient to meet the infant’s requirements for the first 4 to 6 months of life. Additionally, immunologic pro tection is transferred from mother to infant via breast milk and maternal–infant bonding is promoted. Refer to chapter 18 for additional information related to the composition of colostrum, transitional milk, and established breast milk.
BREASTFEEDING TECHNIQUE
Breastfeeding mothers may not have established adequate breastfeeding prior to leaving the hospital after birth of the newborn. The pediatric nurse may encounter an in- fant–mother dyad experiencing difficulty with breastfeed- ing for a variety of reasons. Thus, the pediatric nurse must be competent in counseling the breastfeeding mother.
Before each breastfeeding session, mothers should wash their hands. It is not necessary to wash the breast in most cases. The mother should be positioned comfortably.
A number of positions are possible, and they should be varied throughout the day (refer to chapter 18 for further in- formation related to breastfeeding positions.). The mother
FIGURE 25.9 Stroking the infant’s cheek with the nipple will elicit the rooting reflex.
FIGURE 25.10 Bringing the infant’s open mouth to the breast, rather than bringing the breast to the infant, helps the infant correctly latch on. The infant’s mouth forms a seal around all of the nipple and areola. Note the “C” position for holding the breast during latching on.