the Pediatric curicculum.docx

Blood disorders, or blood diseases are conditions that affect the different parts of your child\'s blood including: -White blood cells -Red blood cell -Platelets -Plasma -Hemoglobin One of the most common blood disorders is called anemia there are many kinds of anemia If your child h...

Blood disorders, or blood diseases are conditions that affect the different parts of your child\'s blood including: -White blood cells -Red blood cell -Platelets -Plasma -Hemoglobin One of the most common blood disorders is called anemia there are many kinds of anemia If your child has anemia they don\'t have enough red blood cell or hemoglobin to carry oxygen through their body \"Hemoglobin is a blood protein that help the cells move oxygen types Iron deficiency anemia,. Sickle cell anemia,. Leukemia Hemophilia Aplastic anemia. Hemolytic anemia. Megaloblastic anemia. Causes Losing red blood cells. Red blood cells being destroyed. Infections. Other diseases. Symptoms Irritability. Headaches. Swollen or sore tongue. Swollen or sore tongue. Slow healing from wounds. Low energy. Sudden loss of vision. Diagnosis and Tests Peripheral smear. Complete blood count (CBC). Hemoglobin hematocrit Treatments Treatments for blood cell disorders depends on what kind of disorder your child has. Anemia treatment depends on what's causing the anemia. Some possible treatment methods include: Blood transfusions. Bone marrow transplants. Stem cell transplants. Drinking lots of water. Medicines that keep your child's blood healthy. Getting your child to eat foods that keep their blood healthy Getting more vitamins and minerals, either from food or pills. Getting your child off medicine that might be causing anemia Iron deficiency anemia Introduction Iron deficiency anemia is a common blood disorder that occurs when red blood cell counts are low due to a lack of iron. Red blood cells need iron to produce a protein called hemoglobin that helps them carry oxygen from the lungs to all the parts of the body. Iron deficiency is the most common cause of anemia in otherwise healthy children in the United States. causes Diets low in iron. Body changes. Gastrointestinal tract abnormalities: Blood loss Genetic causes: Symptoms pale skin, lips, and hands, or paleness under the eyelids. irritability. lack of energy or tiring easily increased heart rate. sore or swollen tongue. a desire to eat peculiar substances, such as dirt or ice (also called pica). Diagnosis Iron deficiency anemia may be suspected based on general findings from a complete medical history and physical examination, such as: complaints of tiring easily. pale skin and lips. fast heartbeat. CBC treatment treatment Iron deficiency anemia treatment may include: Iron-rich diet. Iron supplement. Leukemia Definition Leukemia is a type of cancer of blood or bonemarrow Characterized by an abnormal increase of immature white blood cells called \"blasts\". Leukemia is a broad term covering a spectrum of diseases. Leuka white, emia = blood TYPES Acute leukaemia: Rapid onset. = Aggressive course. Poorly differentiated cells with many blasts. Chronic leukaemia: - Gradual onset. - Less aggressive. Mature cells. Classification of Leukaemias Acute leukaemia Acute lymphoblastic leukaemia Acute myeloid leukaemia Chronic leukaemia Chronic myeloid leukaemia Chronic lymphocytic leukaemia Diagnosis The diagnosis of leukemia is made after a bone marrow aspirate and possibly a bone marrow biopsy. Bone marrow tissue is examined by a pathologist under a microscope. The results of this procedure will show the doctor what type of leukemia the child has. treatment Chemotherapy. Chemotherapy drugs kill cancer cells, control their growth or relieve disease-related symptoms. \... Radiation therapy. Radiation therapy uses power beams of energy to kill cancer cells. \... Stem cell transplantation. \... CAR T cell therapy. \... Targeted therapy. \... Clinical trials. Sickle cell anemia Red blood cells are usually round and flexible. In sickle cell anemia, some red blood cells look like sickles used to cut wheat. These unusually shaped cells give the disease its name. Symptoms Symptoms of sickle cell anemia usually appear around 6 months of age. They vary from person to person and may change over time. Symptoms can include: Causes Sickle cell anemia is caused by a change in the gene that tells the body to make hemoglobin. Hemoglobin is the iron-rich compound in red blood cells that allows these cells to carry oxygen from the lungs to the rest of the body. The hemoglobin associated with sickle cell anemia causes red blood cells to become rigid, sticky and misshapen. Risk factors For a baby to have sickle cell anemia, both parents must carry a sickle cell gene. In the United States, sickle cell anemia most commonly affects people of African, Mediterranean and Middle Eastern descent Cardiovascular disease Introduction Rheumatic fever is a complex disease that affects the joints, skin, heart, blood vessels and brain. It occurs mainly in children between the ages of 5 to 15. It is an autoimmune disease that occurs after an infection with strep (streptococcus) bacteria. Strep infections include strep throat and Definition Rheumatic fever is an inflammatory disease that can develop when strep throat or scarlet fever isn\'t properly treated. Strep throat and scarlet fever are caused by an infection with streptococcus (strep-toe - KOK-us) bacteria. Rheumatic fever most often affects children ages 5 to 15. Signs and symptoms joint inflammation, including swelling, tenderness, and redness over multiple joints. small nodules or hard, round bumps under the skin. a change in your child\'s handwriting, or unusual jerky movements. a pink rash with odd edges. fever. weight loss. fatigue. stomach pains. Laboratory test Tests for rheumatic fever include Blood tests. Blood tests can be done to check for signs of inflammation in the body. These tests include C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR), Treatment Treating Rheumatic Heart Disease in Children with rheumatic fever need medicine (antibiotics) to fight their strep infection. Your child\'s doctor may also prescribe anti-inflammatory medicine to treat joint pain and swelling. They may recommend bed rest for 2 to 12 weeks, Complications Serious complications include long-term heart damage If rheumatic fever is not treated promptly, rheumatic heart disease may occur. Rheumatic heart disease weakens the valves between the chambers of the heart. Severe rheumatic heart disease can require heart surgery and result in death\> Prevention Rheumatoid arthritis prevention -- steps to reducing the risk for those at risk Don\'t smoke. Eat a Mediterranean diet high in vegetables, fruit, olive oil, nuts and wholegrains. Exercise 20-30 minutes a day. Avoid high salt in your diet. Add more fish and omega-3 to your diet. Cut down on sugar-sweetened soft drinks. Nursing diagnosis Nursing diagnosis for congenital heart defects Pain Related to disease Gola Relieve pain Intervention rest Change position, elevate head of bed give analgesic as order improve of knowledge related to disease Gola Improve knowledge about disease Intervention 1teach chill Family about disease sing and symptoms treatment and side effects of medication complications of disease Impair of body temptation more than body requirements related to disease Gola relive tempartion Intervention teach mother to give ice compressions tack shore give antipyretic as order communicable diseases in children Definition: Polio, or poliomyelitis, is a disabling and life-threatening disease caused by the poliovirus. The virus spreads from person to person and can infect a person\'s spinal cord, causing paralysis (can\'t move parts of the body) Causes: Polio is caused by poliovirus. There are 3 types of the virus. It often spreads through contact with infected poop. This often happens when children don\'t wash their hands or don\'t wash them correctly. It can also happen from eating food or drinking water that has the virus. It can be spread when an infected child coughs or sneezes infected droplets into the air. The virus can also be in a child's poop for several weeks. Children are most contagious right before symptoms start. Sing and Symptoms: Fatigue (extreme tiredness) Fever. Headache. Nausea. Sore throat. Stiff neck and back. Stomach pain. Risk Factors: travelling to an area where polio is common or where an outbreak has recently occurred. living with or caring for someone who may be currently infected with the poliovirus. not being immunised and having contact with someone recently immunised with the oral polio vaccine. Complication: Possible complications of paralytic polio can include permanent paralysis of certain muscle groups. This may include the leg muscles, or the muscles used for breathing Prevent: The vaccine is the main way to prevent polio. In the U.S., children are given inactivated polio vaccine (IPV). This is given by a shot. IPV can't cause polio. It's safe for a child with a weak immune system. Oral poliovirus vaccine (OPV) is no longer given in the U.S. OPV contains a live virus and may be less safe than IPV for some children. Nursing diagnosis: Based on the assessment data, the major nursing interventions for polio: Imbalanced nutrition: less than body requirement related to anorexia, nausea, and vomiting. Ineffective thermoregulation related to the infection process. Ineffective airway clearance related to muscle paralysis What is dehydration ? The food you eat makes its way from your stomach to the large intestine or colon. If you don \' t have enough water in your body already the large intestine soaks up water from your food waste. This makes you have hard stools that are difficult to pass. Types of dehydration There are three main types of dehydration : hypotonic primarily a loss of electrolytes ). hypertonic primarily loss of water ) and isotonic equal loss of water and electrolytes.) The most commonly seen in humans is isotonic. causes dehydration Dehydration is caused by not drinking enough fluid or by losing more fluid than you take in. Fluid is lost through sweat tears vomiting urine or diarrhoea. The severity of dehydration can depend on a number of factors such as climate level of physical activity and diet. symptoms of dehydration be extremely thirsty. have a very dry mouth. be breathing fast. have a fast heart rate and a low blood pressure. have a fever. have little or no urine wee ) dehydration of effects serious \.... problems hypovolemic shock.) kidney shock and volume Urinary \... blood. injury Low \... Heat. Seizures Treatment If you are mildly dehydrated the best thing you can do is to drink more water. You can also drink oral rehydration solutions that you buy from your pharmacy. diarrhea more or chronic or three persistent stools acute watery be may is loose Diarrhea. day Diarrhea times a Types osmotic transit diarrhea : categories intestinal four rapid. into classified exudative is Diarrhea secretory cause persistent effects of medicines and side acute and of causes common most diarrhea are infections. The symptoms...... pain Bloating Vomiting Fever stool stool the the. Nausea in in movement Blood Mucus bowel a have to need Urgent complications kidney failure. and stool. even water or of imbalance plenty loses electrolyte body dehydration our Diarrhea In Treatment Antidiarrheal medication These include loperamide Imodium ) and bismuth subsalicylate Pepto-Bismol.) Imodium is an antimotility drug that reduces stool passage. Pepto Bismol reduces diarrheal stool output in adults and children DIARRHEA IN PEDIATRIC DEFINITION Excessive loss of fluid and electrolytes in stool, increase in liquidity. A more exact definition is excessive daily stool liquid volume ( \>10 ml stool/kg body weight/day). Diarrhea in pediatric Increase in stool frequency to twice the usual number per day in infants or three or more loose or watery stools per day in older children. ETIOLOGY 1. Infection. 2. Drugs. 3. Dietary causes. 4. Surgical conditions. 5. Miscellaneous causes. CLASSIFICATION 1. On the basis of duration: Acute diarrhea Chronic diarrhea 2. On the basis of clinical presentation: Acute watery diarrhea Acute bloody diarrhea CONT.. 3. On the basis of physiology: Secretory e.g cholera Osmotic e.g lactose intolerance Exudative e.g rotavirus Motility related Inflammatory e.g invasive bacteria CLINICAL Clinical symptoms in general: Nausea Vomiting Fever Abdominal pain & cramp TYPE OF CLINICAL There are 2 types: vAcute watery diarrhea ( most common): Usually within 48h of presentation , is usually self limiting. Main complication is dehydration. vAcute bloody diarrhea (dysentery): Sepsis , malnutrition , dehydration and HUS " hemolytic uremic syndrome " DIAGNOSTIC 1. History taking 2. Physical examination 3. Stool examination 4. Stool culture 5. Blood tests MANAGEMENT Replacement of the fluids Administration of prescribed drugs Maintenance of nutritional status Educate the mother regarding prevention of diarrhea NURSING ASSESSMENT 1. Assess onset and pattern of diarrhea. 2. Assess characteristics and number of stools. 3. Obtain a stool culture. 4. Assess for abdominal pain and related symptoms. 5. Assess bowel sounds. 6. Monitor electrolyte imbalances. 7. Assess gastrointestinal history. NURSING DIAGNOSIS qDiarrhea related to malabsorption secondary to irritable bowel syndrome, as evidenced by more than three loose stools per day. vGoal Patient will defecate Bristol stools type 3 or 4 no more than twice per day. vIntervention Administer medications as ordered. Most antidiarrheal drugs suppress gastrointestinal motility, thus allowing for more fluid absorption. Instruct the dietary modifications: Bulk fiber , Natural bulking agents and avoidance of stimulants. CONT.. Encourage fluids 1.5 to 2 L per day. Provide perianal care after each bowel movement. Hygiene reduces the risk of perianal skin excoriation and promotes comfort. Explain how to prevent the spread of infectious diarrhea. Good hand hygiene. qDiarrhea related to lactose deficiency as evidenced by cramping and abdominal pain. vGoal Patient will verbalize relief from abdominal pain and cramping. vIntervention Instruct or administer lactase supplement as indicated. CONT.. Instruct on dietary changes. The core management of lactose intolerance is to modify the diet. Administer medications as ordered. Antidiarrheal drugs decrease GI motility, relieve abdominal pain/cramping, and prevent further fluid losses. Educate about lactose intolerance and its management. Instruct about reading food labels. Emergency care of pediatric Poisoning poison is a substance capable of producing adverse effects on an individual under appropriate conditions.Poisoning Most poisonings in children are unintentional and occur in the home. More than half of reported poisonings occur in children under age five. A child may become curious and ingest a toxic substance, inhale it, or absorb these substances through the skin. What is the management of poisoning? The first step is to stabilize airway, breathing, and circulation as with any critically ill patient. Identifying the poison, either through history, toxidrome, or laboratory tests may direct the physicians in the right track. Antidotes can be used in instances where the exact poison agent is known. Drowning the pediatric setting, the highest drowning rate has been observed in children between the first and fourth years of life, with a second peak in adolescents aged between 15 and 19 years Drowning Drowning Signs And Symptoms: persistent coughing. difficulty breathing. tiredness. decreased activity. mental confusion. blue colour on skin and lips. loss of consciousness. loss of bowel or bladder control What is the first aid procedure for drowning? Take a breath and place your lips around the casualty\'s mouth, forming a seal. Blow into the casualty\'s mouth until the chest rises. Follow by beginning chest compressions. Kneel by the casualty and put the heel of your hand in the middle of their chest. Shock Introduction. Shock is a life threatening condition caused by the systemic failure of the circulatory system. What is shock in pediatrics diagnosis? Shock is a clinical diagnosis. Classically, pediatric shock manifests with signs/ symptoms indicative of decreased organ perfusion or poor peripheral perfusion, Seek emergency medical care Keep the person still and don\'t move the person unless necessary. Begin CPR if the person shows no signs of life, such as not breathing, coughing or moving. Loosen tight clothing and, if needed, cover the person with a blanket to prevent chilling. Don\'t let the person eat or drink anything. Burns Greatest number of pediatric burn patients are infants and toddlers younger than 3 years of age burned by scalding liquids. Male children are at increased risk, often due to fire play and risk-taking behaviors. Female children are at increased risk, with most burns occurring in the kitchen or bathroom. What is the most important treatment for burns? For serious burns, after appropriate first aid and wound assessment, your treatment may involve medications, wound dressings, therapy and surgery. The goals of treatment are to control pain, remove dead tissue, prevent infection, reduce scarring risk and regain function. Type of Burns Chemical Burns. \... Electrical Burns. \... Friction Burns. \... Radiation Burns. \... First-Degree Burns. \... Second-Degree Burns. \... Third-Degree Burns. Foreign body foreign body (FB) ingestion in children is very common, and most events occur in children between 6 months and 3 years of age. Notably, 80%--90% of FBs in the gastrointestinal (GI) tract are passed spontaneously without complications, 10%--20% are removed endoscopically, and 1% require open surgery secondary to com foreign body\> Febrile convulsions CONTENT: Definition. Type. Risk factors. Causes. Sign and symptoms. Treatment. Nursing Care Plan. INTERDICTION: Convulsions is condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body. DEFINITION: Febrile Convulsions are fits that can happen when a child has a fever. They most often happen between the ages of 6 months and 3 years. Type : There are two types of febrile convulsions Simple : They\'re usually over in a few minutes, but in rare cases can last up to 15 minutes and it\'s more common. Complex : Last longer. Causes : High fever. high or low blood sugar. Abnormal levels of sodium. Brain infection, including meningitis and encephalitis. Brain concussion. Sign and symptoms : loss of consciousness Twitching of arms and legs. Breathing difficulty. Foaming at the mouth. Going pale or bluish in skin colour. Eye rolling, so only the whites of their eyes are visible. The child may take 10 to 15 minutes to wake up properly afterwards Investigation : A blood test. A urine test. A spinal tap ( lumbar puncture ). EEG. Neuro image ( CT , MRI ). Sefety precautions : Place child on his or her side on a soft, flat surface where he or she won\'t fall. close to watch and comfort your childt Remove hard or sharp objects near your child. Loosen tight or restrictive clothing. Treatment : Tegretol Phenytoin Phenobarbital. Nursing Care Plan : Nursing diagnosis : Hyperthermia related to microorganisms that cause inflammation. Goal : Maintain normal body teamprture. Intervention : Monitor the child\'s temperature ( tympanic or rectal temperature ). Nursing Care Plan : Nursing Diagnosis : Deficient Knowledge new disease or lack of exposure to information about ongoing care. Goal : Provide knowledge. Intervention : Provide information about disease condition , fears , and misconceptions about disorder , nature , and frequency of convulsion. introduction: The nervous system contains a fluid called cerebrospinal fluid. Fresh cerebrospinal fluid is made continuously by the brain every day. It circulates around the brain and spinal cord, carrying nutrients. DEFINITION: Hydrocephalus is the accumulation of too much fluid in the brain and spinal cord. Diagnosing: To diagnose hydrocephalus, a neurosurgeon or neurologist takes a thorough medical history and performs a neurological evaluation and physical exam. Doctors then perform an ultrasound, MRI scan, or CT scan to confirm enlargement of the ventricles and determine the cause of the hydrocephalus. Causes hydrocephalus in children: Hydrocephalus is typically a symptom of some other problem, and a pediatric neurologist and neurosurgeon can to determine the cause. Sometimes hydrocephalus develops during pregnancy and in other cases, after birth. Several conditions can result in blocked cerebrospinal fluid. Treatment: The most common hydrocephalus treatment is a shunt, a small piece of silicone tubing placed surgically inside the body to bypass a blockage or otherwise create a better flow of cerebrospinal fluid. Nursing care plans and Management: The nursing care planning goals for a client with hydrocephalus include monitoring and maintaining adequate cerebral perfusion pressure, promoting optimal neurological function, preventing complications related to increased intracranial pressure, and educating the client and the family about the condition and its management. Anthropometric/Growth Anthropometric/Growth Measurements Measurements Anthropometric/Growth Measurements Anthropometric/Growth Measurements ϖGrowth measurements components are: (A): Length/height. (B): Weight. (C ): Head circumference. (D): Chest circumference. (E): Midarm circumference. (F): Skinfold thickness. A). Measuring Growth in Length and Stature A). Measuring Growth in Length and Stature ◦ Recumbent length is measured from birth until a child is able to stand Measured from the vertex (highest point on skull) to the soles of the feet Procedure Procedure Equipments: hard surface, measuring tape, measuring board. Put the infant in recumbent position. Place supine with head in midline. Grasp knee and push gently toward table to fully extended legs. Measure from vertex of head to heel of feet to nearest centimeter. Read &record. A). Measuring Growth in Length and Stature A). Measuring Growth in Length and Stature Stature/ or standing height is measured between the vertex and the floor. Procedure Procedure Remove socks &shoes. Have child stand as tall as possible, back straight, head in midline, and eye looking straight a head. Check for flexion of knees, slumping shoulders raising of heels. Measure from top of head to standing surface. Measure to the nearest centimeter. A). Length/Stature \< 3y ≥3y Supine Stand\-\-- \-\-- Length Stature A). Length/Stature \< 3y ≥3y Supine Stand\-\-- \-\-- Length Stature Stature-for-Age http://www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module3/text/page3d.htm Use these charts to determine if an individual is growing normally Stature-for-Age Percentiles Growth Curves Growth Curves Boys: 2 to 18 years Girls: 2 to 18 years Boys reach most of their height at age of 17 whereas girls reach theirs at around 15 Boys reach most of their height at age of 17 whereas girls reach theirs at around 15 A). Growth in Length and Stature A). Growth in Length and Stature at birth 50cm 1 year old 75cm 2 years old 85 cm 2\--12 years old=age × 6 + 77 B). Measuring Body Weight B). Measuring Body Weight Electronic digital scales, calibrated in metric units are recommended Procedure Procedure Equipments: platform-type scale for infants & young children Check that scale is balanced before weighing. Cover scale with clean sheet or paper for each child. Weight infant & young children nude, protect infant by placing hand over body to prevent falling off scale. Weight older children in underwear, remove shoes, and put gown if privacy is Procedure Procedure 1. 2. Usual finding; Plot in growth chart. Compare value with percentile for age. B). Measuring Body Weight Birth weight 3 kg ϖ ϖ ϖ First four months weight increase ¾kg every month Second four months weight increase ½ kg every month. Third four months weight increase ¼ kg every month Weight loss: Physiological weight loss: 3 - 9% Physiological weight loss: 3 - 9% recover at 7-10th day recover at 7-10th day Loss of 3%\~ 9% of birth weight in the f irst few days of life is considered normal and is common for most C). Head Circumference C). Head Circumference Ratio of head size to overall body length ◦ Head contributes 25% to body length Head circumference ◦ Indicative of brain development C). Head Circumference HC is a measurement of perimeter of head,from eyebrows to occipital prominence. The change of the HC is related with the growth of brain and skull. Measuring Head Circumference C). Head Circumference C). Head Circumference At birth 34 cm 1 year 46cm 2 years 48 cm 5 years 50cm 15 years 54cm (the same as adult) C). Changes in Head Circumference C). Changes in Head Circumference ϖ Head circumference should be measured with a tape measure at each visit during the first two years of life. ϖ ϖ A large head may be an early sign of hydrocephalus or an intracranial mass. A small head may be a result of early closure of sutures or lack of brain D). Chest Circumference D). Chest Circumference represent the growth of thorax and lung at birth CC\> HC 1- 2 cm 1 year CC= HC Procedure Procedure Equipments: measuring tape Measure around the chest at nipple line. Take measurements during inspiration & expiration, record the average of the two values. Midarm circumference. E). E). Midarm circumference. Equipments: measuring tape. With the child's right arm flexed 90 degree at elbow, mark midpoint between acromion and olecranon process on posterior aspect of arm. Wrap the measuring tape around upper arm at midpoint. A C is an indirect measure of total muscle Skinfold thickness. F). F). Skinfold thickness. Equipments: special caliper. Mark midpoint as done before. With arm hanging freely, grasp a fold of skin between thumb and forefinger I cm above midpoint. Gently pull fold away from underlying muscle and continue to hold until Skinfold thickness. F). F). Skinfold thickness. Place caliper jaw over skin fold at mid point mark. Estimate reading to nearest I mm, 2 to 3 seconds after applying pressure. Skinfold thickness is an index of total body fat. Can be taken at triceps (most common site), subscapula, abdomen or Procedure Procedure 1. 2. Usual finding; Plot in growth chart. Compare value with percentile for age. Otitis media Otitis media is an acute URTI that affects the respiratory mucosa of the middle ear cleft. It is a common illness in young children and occurs much less frequently in children more than 6 years old Symptoms Ear pain, especially when lying down Tugging or pulling at an ear Trouble sleeping Crying more than usual Fussiness Trouble hearing or responding to sounds Loss of balance Fever of 100 F (38 C) or higher Drainage of fluid from the ear Headache Loss of appetite Causes An ear infection is caused by a bacterium or virus in the middle ear. This infection often results from another illness --- cold, flu or allergy --- that causes congestion and swelling of the nasal passages, throat and eustachian tubes. Diagnosis Your doctor can usually diagnose an ear infection or another condition based on the symptoms you describe and an exam. The doctor will likely use a lighted instrument (an otoscope) to look at the ears, throat and nasal passage. He or she will also likely listen to your child breathe with a stethoscope. Treatment Some ear infections resolve without antibiotic treatment. What\'s best for your child depends on many factors, including your child\'s age and the severity of symptoms. Antibiotic therapy After an initial observation period, your doctor may recommend antibiotic treatment for an ear infection in the following situations: Nursing Diagnosis Acute pain related to inflammation and increased pressure from fluid accumulation in the middle ear. Anxiety related to health status. P R E S C H O O L Implement nursing care related to normal growth and development of a preschooler, such as preparing a preschooler for an invasive procedure. INTRODUCTION The preschool period traditionally includes ages 3 to 6 years. Physical growth is more slowly compare to earlier years Mastering the previous learned skills. Preparation for success in school occurs during this age. PHYSICAL DEVELOPMENT Change in body contour. Preschool Toddler Lymphatic tissue increase in size, particularly the tonsils. Levels of IgG and IgA antibodies increase. These changes tend to make preschool illnesses. Weight, Height, and Head Circumference: The average preschool age child will grow 2.5 to 3 inches (6.5--7.8 cm) per year. Weight gains approximately 1.8 kg/year. Head circumference not longer needed ??? Pulse rate: 85 beats per minute. BP: 100/60 mm Hg. Muscles are stronger. Teeth Children generally have all 20 of their deciduous teeth by 3 years of age. Developmental Milestones MOTOR SKILL DEVELOPMENT Gross Motor Skills: Pre school can: Standing, walking, running, and jumping easily. Throw and catch a ball well Rides tricycle -- using pedals Walk forward and backward easily. Fine Motor Skills: Preschooler is able to: Copy a circle. Feed himself without spilling much. Baths himself with assistance. Write letters, cut with scissors more accurately (at 5 years) Tie shoelaces. COGNITIVE DEVELOPMENT Knows age and residence. Identifies heavier of two objects. Knows days of weeks and time units. Knows primary colors. Can count to 10. Have Magical thinking. Often they have an imaginary friend, this behavior help to promote behaviors and practice conversational skills. Not yet aware of the property of conservation. Language development Has a vocabulary of about 900 words Is able to construct sentences using 3 to 4 words. Use telegraphic speech: using short sentences that contain only the essential information. Listens to other people\'s conversations and may participate in the late stage. Can express their needs, wants. Can follow multi-step instructions. Can name body parts, animals, and familiar locations are learned They enjoy participating in mealtime conversation. Like to ask questions constantly, mostly "how" and "why" questions, such as "Why is snow cold? How do worms hear? What does your tongue do? The culture play major role in language development and vocabulary. Moral and Development Learning sense of right and wrong and correct behavior to avoid punishment. Determine right from wrong based on their parents' rules. They have little understanding of the rationale for these rules. Don ' t confuse the preschooler children regarding rules. Emotional Development The developmental task of the preschool years is to form a sense of initiative versus guilt. Less dependent on parents but needs their assurance. Most children of this age want to do things for themselves. Preschooler fear from body injury and strange objects. Oedipus and Electra Complexes appear. Socialization: Preschooler are capable of sharing, they play with other children their age. Enjoy play groups, they may become involved in arguments. Continues to enjoy fantasy play GROWTH AND DEVELOPMENTISSUES IN THE PRESCHOOL CHILD Small Group Discussion 4 groups NURSING DIAGNOSIS: Risk for injury related to developmental age, environment, and motor vehicle travel OUTCOME IDENTIFICATION AND EVALUATION: Child's safety will be maintained, Child will remain free from injury NURSING INTERVENTION: NURSING DIAGNOSIS: Imbalanced nutrition, less than body requirements, related to inappropriate nutritional intake to sustain growth needs (excess juice or milk intake, inadequate food variety intake) as evidenced by failure to attain adequate increases in height and weight over time OUTCOME IDENTIFICATION AND EVALUATION: Child will consume adequate nutrients, Child will demonstrate weight gain and increases in height. NURSING DIAGNOSIS: Interrupted family processes related to issues with preschool child's development or situational crisis as evidenced by parental verbalization of difficulty with current situation. OUTCOME IDENTIFICATION AND EVALUATION Family will demonstrate adequate functioning, Family will display coping and psychosocial adjustment. SCHOOL AGE learning objectives By the end of this lecture the student should be able to: Describe the normal growth and development pattern of school-age period. Assess a school-age child for normal growth and development milestones. Discuss nursing diagnoses that speak to school-age children Explain anticipatory guidance to prevent problems of growth and development in a school age child 12-year-old girl who recently started middle school, her mother tells you that although Shelly, who is overweight, says she likes school; she has developed a lot of nervous habits such as nail biting since school started. Her mother asks if this is normal? Introduction: The term "school age" commonly refers to children between the ages of 6 and 12. Cognitive growth and development continue to proceed at rapid rates. Children of school age may also be more influenced by the attitudes of their friends than previously. The school-age period is usually the first time children begin to make truly independent judgments. Physical Growth School-age children's annual average weight gain is approximately (1.3 to 2.2 kg). The increase in height is 1 to 2 in (2.5 to 5 cm) per year. Posture becomes more erect The lymphatic system grows so rapidly, this results in an massiveness of tonsillar and adenoid tissue in the early school years. The pulse rate decreases to 70 to 80 beats per minute; blood pressure rises to about 112/60 mm Hg Teeth: Deciduous teeth are lost and permanent teeth erupt during the school-age period. The average child gains 28 teeth between 6 and 12 years of age: the central and lateral incisors; first, second, and third cuspids; and first and second molars. Developmental Milestones Gross Motor Development: During the school-age years, coordination, balance, enough eye hand coordination. And rhythm improve, facilitating the opportunity to ride two ride bicycle. Gender differences usually begin to manifest in play: there are "girl games," such as dressing dolls, and "boy games," Fine Motor Development: Can easily tie their shoelaces. They can cut and paste well and draw a person with good detail. Language Development Talk in full sentences, using language easily and with meaning. They know the months of the year and can name the months in which holidays fall. Can carry on an adult conversation, although stories are limited because of their lack of experience. Emotional Development Children enter the school-age period with the ability to trust others and with a sense of respect for their own value. They can accomplish small tasks independently because they have gained a sense of industry. Developmental Task: Industry Versus Inferiority Sense of initiative can be defined as learning how to do things, then gaining a sense of industry is learning how to do things well. If children are prevented from achieving a sense of industry or do not receive rewards for accomplishment, they can develop a feeling of inferiority or become convinced they cannot do things they actually can do. In late school age begin to spend more and more time with their peers and less time with their family. Cognitive Development The period from 5 to 7 years of age is a transitional stage where children undergo a shift from the preoperational thought they used as preschoolers to concrete operational thought or the ability to reason through any problem they can actually visualize. Moral and Spiritual Development begin to mature in terms of moral development as they enter a stage of preconventional reasoning, some-times as early as 5 years of age (Kohlberg, 1984). During this stage, if asked, "Why is it wrong to steal from your neighbor?" school-age children will answer, "The police say it's wrong," or "Because if you do, you'll go to jail." begin to learn about the rituals and سوقطmeaning behind their religious practices, so the distinction between right and wrong becomes more important to them. Parent role modeling is also important. What is developmental task of school age child according to psychosexual theory? PROBLEM 12-year-old girl who recently started middle school, her mother tells you that she is overweight, says she did not likes school; she has developed a lot of nervous habits such as nail biting since school started. Her mother asks if this is normal. Because of still limited judgment, school children need guidelines in reference to safety, nutrition, and daily care. Promoting School-Age Safety At school age the parents must to look at the effect of carrying heavy backpacks on children's posture. Sexual abuse is an unfortunate and all too-common hazard for children. Teach street-crossing safety; stress that streets are no place for play or pushing. Teach bicycle safety, including advice not to take "passengers" on a bicycle and to use a helmet. Do not go with strangers.. Children should say "no" to anyone who touches them if they do not wish it, including family members. Promoting Nutritional Health of a School-Age Child Most school-age children have good appetites, although any meal is influenced by the day's activity. School-age children need provide breakfast to enough energy to get them through active mornings at school. If children take a packed lunch to school, urge parents to allow them some say in the meal. Most children are hungry after school and enjoy a snack when they arrive home. Care of Teeth School-age children have to be reminded to brush their teeth daily. Common Health Problems of the School-Age Period Dental Caries: Dental caries are largely preventable with proper brushing and use of fluoridated water or fluoride application. When caries do occur, it is important they be treated quickly and the child's dental hygiene practices be evaluated and improved if necessary. Addressing Common Developmental Concerns Television and Video Games Limit television watching and video game playing to 2 hours per day. Monitor television programs. Prohibit television or video games with violence. Do not put television or video games in children's bedrooms. Provide a schedule of accepted television programs for viewing each week. School Refusal or Phobia: Children who resist attending school this way may develop physical signs of illness, such as vomiting, diarrhea, headache, or abdominal pain on school days. School refusal may occur from fear of separation from parents. The child may be overly dependent on the parents or may be fear to leave home because of worry that younger siblings will have the parents' affection Parent education include: Return child to school. Investigate cause of the fear. Support child. Collaborate with teachers. Praise success in school attendance Fear: They fear death and are fascinated by death and dying. They are less fearful of dogs and noises. The school-age child needs reassurance that his or her fears are normal for this developmental age. Stealing: Stealing occurs because, although a child is gaining an appreciation for money, this appreciation is not yet balanced by strong moral principles. As a rule, early childhood stealing is best handled without a great deal of emotion. A parent should tell the child the money is missing. Educate parents about possibility of stealing. Discuss ways to teach concept of ownership and rights. Assist child in developing and enacting a plan to return what was stolen. Make sure the punishment is appropriate for the action Laying Help parents in understanding why the child is lying. When the child lies, calmly confront the child and explain why the behavior is not acceptable. Educate parents that too-rigid or severe punishments can decrease the child's sense of self value. Cheating Educate parents that the child must be mature enough to understand the concept of rules. Handle cheating situations openly. Help parents to understand why their child is cheating and to modify the trigger problems Develop appropriate punishment. Educate parents that their behavior should reflect what they expect from their child. Seek professional help if cheating persists in the older school-age child, to rule out underlying Questions ? Summary The school age average annual weight gain is 3 to 5 lb; their increase in height is 1 to 2 inches. Deciduous teeth are lost and permanent teeth erupt during the school-age period. Erikson's developmental task for the school-age period is to gain a sense of industry, or how to do things well. Common health problems during the school-age period include minor respiratory and gastrointestinal infections as well as dental caries. School-age children are looking for good adult role models; it is hard for them to feel confidence in an adult who is not honest with them. URINARI DISORDERS INTRODUCTION: Urinary tract disorders include a variety of problems that affect the urinary system in children These disorders may include bladder infections ,kidney infections ,bedwetting , urinary tract obstruction ,developmental abnormalities ,urinary stones ,and excessive nocturnal urination Urinary tract infections in children are common and can be painful and annoying. The causes and types of urinary tract infections in children may differ from those that occur in adults. Causes of urinary tract infections in children: 1 Improper cleaning agents: Bacteria can move from the external genital area to the urinary tract as a result of not cleaning this area well. 2 Urine impaction: When a child has difficulty urinating or refrains from urinating for a long time, urine can become impacted in the bladder or urethra, and this contributes to increasing the chances of urinary tract infections. 3 Urinary accumulation disorders: Some children may suffer from disorders that affect the urine drainage process and increase the chances of developing urinary tract infections. Types of urinary tract infections in children: 1 Cystitis :It occurs when the bladder becomes infected with a bacterial infection 2 Urethritis :It occurs when the tubes that transport urine from the bladder to the kidneys become infected with a bacterial infection 3 Nephritis :It occurs when the kidneys become infected with a bacterial infection Treatment of urinary tract infections in children: Treatment of urinary tract infections in children includes the following: 1 Use appropriate antibiotics according to the doctor's recommendations 2 Increase fluid intake to help flush the urinary tract and relieve symptoms 3 Follow a healthy and balanced diet to enhance the health of the urinary system Complications of urinary tract infections in children: If urinary tract infections are not treated properly ,possible complications such as kidney infection and blood poisoning may occur Therefore ,you must monitor the symptoms and consult a doctor if you suspect that the child has a urinary tract infection Risk groups \*\* - Women \*\*:Due to the shortness of the urethra and its proximity to the anus ,which facilitates the entry of bacteria into the urinary tract \*\* - Pregnancy \*\*:Pregnancy increases the risk of urinary tract infections \*\* - Repeated use of certain types of contraceptives \*\*:such as diaphragm or internal condoms \*\* - Sexual activity \*\*:People who are sexually active are more likely to develop UTIs \*\* - Advanced age \*\*:The incidence of infections increases with age Nephrotic syndrome Nephrotic syndrome is a disorder that affects the kidneys and causes an excessive amount of protein to be excreted in the urine Nephrotic syndrome usually results from damage to clusters of small blood vessels in the kidneys ,which filter waste and excess water from the blood- The condition causes swelling ,especially in the feet and ankles ,and increases the risk of other health problems¹² \*\* 2 Symptoms of nephrotic syndrome:\*\*- Severe swelling( edema ,)especially around the eyes and in the ankles and feet- Foamy urine due to excess protein in the urine- Weight gain due to fluid retention- Fatigue and loss of appetite¹³ \*\* 3 Causes and risk factors:\*\* Damage to the clusters of tiny blood vessels( glomeruli )in the kidneys is usually caused by nephrotic syndrome- Many diseases and conditions Many diseases and conditions can cause glomerular damage and lead to nephrotic syndrome , including diabetes and focal segmental glomerulosclerosis¹³⁴ \*\* 4 Treatment:\*\* Treatment for nephrotic syndrome includes treating the condition causing it and taking medications Nephrotic syndrome can increase the risk of infection and blood clots- Your doctor may recommend medications and diet changes to prevent complications¹ \*Progression of the disease:\*\* If early diagnosis and effective treatment are not provided ,damage to the kidneys may lead to serious health problems Complications Nephrotic syndrome can lead to an increased risk of infection and blood clots It may also affect the cardiovascular and nervous systems Early diagnosis It is important to detect early nephrotic syndrome and begin appropriate treatment to reduce complications It is always best to consult a doctor if you experience symptoms that suggest nephrotic syndrome Early diagnosis and appropriate treatment can improve treatment outcomes Diet to prevent\*\* kidney disease syndrome:\*\* 1\*\* Low-fat meat:\*\*- Eat low-fat meats such as fish ,shellfish and poultry \*\* 2 Fresh fruits:\*\*- Includes apples ,pears ,watermelon ,and oranges \*\* 3 Fresh and packaged low-salt vegetables:\*\*- Such as beans and lettuce The diet for patients with nephrotic syndrome depends on the patient\'s weight and age Acute glomerulonephritis Acute glomerulonephritis is a condition that affects the glomeruli ,the tiny filters in the kidneys that filter fluids and waste from the blood Acute glomerulonephritis can be caused by several factors ,such as infections ,autoimmune diseases , medications ,or toxins Acute glomerulonephritis can lead to kidney damage and failure if it is not treated quickly and effectively Symptoms of acute glomerulonephritis:- The color of urine changes to pink or the color of a cola drink due to the presence of red blood cells in the urine- Foamy or bubbly urine due to excess proteins in the urine- Hypertension- Fluid retention and swelling in the face ,hands ,feet and abdomen- The amount of urine is less than usual- Nausea and vomiting- Painful muscle contractions- Exhaustion Diagnosis To diagnose acute glomerulonephritis ,urine , blood and kidney tests must be performed ,and it may be necessary to take a biopsy of kidney tissue to examine it under a microscope Treatment depends on the cause ,severity ,and complications ,and may include: -Anti-inflammatory and autoimmune medications , such as steroids ,cyclophosphamide or rituximab- Anti-infective medications ,such as antibiotics or antivirals- Medications to lower blood pressure and control blood sugar levels ,if there is accompanying diabetes- Dialysis or dialysis ,in the event of acute kidney failure ,blood poisoning ,or disturbance in the balance of fluids and minerals- Kidney transplantation ,in the event of chronic kidney failure and failure to respond to other treatments causes of acute glomerulonephritis The causes of acute glomerulonephritis vary depending on the type of inflammation and the factors causing it Some common causes are: -Bacterial or viral infections ,such as strep throat ,endocarditis ,hepatitis or HIV¹²- Autoimmune diseases ,in which the immune system attacks healthy tissue in the kidneys , such as lupus or Goodpasture syndrome¹²- Medications or toxins that cause irritation or damage to the glomeruli ,such as some antibiotics ,pain medications ,or radioactive dyes¹² Risk Factors Some risk factors that increase the likelihood of developing acute glomerulonephritis are:- Family history of kidney disease or infection²- Immune system diseases or diabetes¹²- Taking too many antibiotics or pain medications²- Recently had urology surgery² complications Some of the complications that may result from acute glomerulonephritis are:- Kidney damage and failure ,which requires dialysis ,dialysis ,or a kidney transplant¹²- High blood pressure and cholesterol ,which increases the risk of cardiovascular disease¹³- Blood clots in the veins or arteries ,causing a blockage in the blood circulation and threatening life¹³- Damage to other organs in the body ,such as the skin ,eyes ,nerves ,or lungs. \+ Learning objectives By the end of this session the learner should be able to: 1.Describe normal growth and development of a toddler 2.Identify the gross and fine motor milestones of the toddler. 3.Assess a toddler for normal growth and development milestones. 4. Identify common developmental issues of toddler. 5. discuss nursing diagnoses related to toddler growth and development or parental concerns regarding growth and development. Jasmine is a 2 ½ -year-old girl you see at a pediatric clinic. Her mother tells you she has changed completely in the past 6 months from an easy-to-care-for baby into a "monster" who refuses to do anything she asks. The only word he says anymore is "no." He has a temper tantrum every night at dinner over some type of food. She tells you this has changed parenting from "fun" to "a real chore." Jasmine's mother tells you Jasmine eats "almost nothing." What are questions arise on your head? Introduction Toddler is the age from 1 to 3 years. Enormous changes take place in a child and, consequently, in a family. Toddler are able to fulfillment of most needs such as to walking, talking with a growing sense of autonomy. Physical growth Weight: A toddler gains only about 2.5 kg and 12 cm a year The toddler shape changes from a inflate baby into a leanerةقاشر, more muscular child. Toddlers tend to have a prominent abdomen because abdominal muscles are not yet strong enough to support abdominal contents. A toddler's appetite decreases accordingly; so attention should be made for quality and quantity of food? Head circumference increases only about 2 cm during the second year. Head circumference equals chest circumference at 1 year of age. By 2 years, chest circumference has grown greater than that of the head. Physiological development: Respirations slow slightly but continue to be mainly abdominal. The heart rate slows from 110 to 90 beats per minute; blood pressure increases to about 99/64 mm Hg Developmental Milestones Gross Motor Skills As gross motor skills such as " walking, running and jumping" are mastered the large muscle groups in the toddler are strength. Fine Motor Skills Fine motor skills in the toddler period are improved and perfected. 12-15 month Feeds self finger foods Uses index finger to point 18 month Grasping, and puts things in box 36 month: Undresses self Holds a pencil in writing position Copies circle. SENSORY DEVELOPMENT According to cognitive theory the toddler fall within sensory motor stage. Toddlers may exhibit preferences for certain flavors of foods. Lack of complete taste discrimination places the toddler at risk of accidental ingestion. LANGUAGE DEVELOPMENT Because toddlers are increasing in cognitive development, they are able to listen to and understand short explanations. Language is about fulfilling needs; "I do" or "want drink." The toddler moves from using single words to short phrases. PSYCHOSOCIAL DEVELOPMENT The child begins to develop a sense of self as separate from his mother " autonomy " while in some way maintaining enough connection to feel secure. How to promote this sense? MORAL DEVELOPMENT Cognitively, the toddler is still a very concrete thinker and knows that something is "good" or "bad," but does not know why. At this stage, the toddler identifies good and bad, right and wrong by virtue of whether or not it is rewarded or punished. " Kohlberg development theory ' s moral " EMOTIONAL DEVELOPMENT Less fear of strangers, but he develops separation anxiety. Temper--tantrums as mans of anger expression. Afraid from falling, loud voice and strange places and people. ADDRESSING COMMON DEVELOPMENTAL CONCERNS Toilet training Toddler can control of the urinary and anal sphincters by the age of 2 years. Signs of readiness for toilet training: 1. Bowel movements occur on a fairly regular schedule. 2. The toddler expresses knowledge of the need to defecate or urinate. (This may be through verbalization, change in activity, or gestures) such as: o Looks into or grabs diaper o Crosses legs o Grimaces and/or grunts o Hides behind a door or the couch when defecating. 3. The diaper is not always wet (this indicates the ability to hold the urine for a period of time). 4. Willing to follow instructions. 5. Walks well alone and is able to remove his clothes. 6. The toddler follows caregivers to the bathroom. 7. The toddler climbs onto the potty chair or toilet. Negativism Parents should understand that this negativism is a normal developmental occurrence and not necessarily deliberate defiance. Avoid asking yes-or-no questions, as the toddler's usual response will be "no," whether he or she means it or not. Offering the child simple choices will give the toddler a sense of control. The parent should not ask the toddler if he or she "wants" to do something, if there is actually no choice. Temper Tantrums Temper tantrums are a natural result of the frustration that toddlers experience. Parents need to learn their toddler's behavioral cues in order to limit activity that is frustrating. When the parent notes the beginnings of frustration, a friendly warning might be given. Use distraction, refocusing, or removal from the situation. Nursing diagnosis Jasmine is a 2 ½ -year-old boy you see at a pediatric clinic. His mother tells you he has changed completely in the past 6 months from an easy-to-care-for baby into a "monster" who refuses to do anything she asks. The only word he says anymore is "no." He has a temper tantrum every night at dinner over some type of food. She tells you this has changed parenting from "fun" to "a real chore." What is probable nursing diagnosis ??? Delayed growth and development Imbalanced nutrition, less than body requirements Interrupted family processes Risk for caregiver role strain Risk for injury SGD 3 GROUPS 3 NURSING DIAGNOSIS 10 MINUTES PROCESS 10 MINUTES PRESENTATION AND DISCUSSION. GROUP ( 1 ) NURSING DIAGNOSIS: Risk for injury related to curiosity, increased mobility, and developmental immaturity. GROUP (2) NURSING DIAGNOSIS : Imbalanced nutrition, less than body requirements, related to inappropriate nutritional intake to sustain growth needs (excess juice or milk intake, inadequate food variety intake) as evidenced by failure to attain adequate increases in height and weight over time. GROUP (3) NURSING DIAGNOSIS: Interrupted family processes related to issues with toddler development, parental verbalization of difficulty with current situation. NURSING DIAGNOSIS: Risk for injury related to curiosity, increased mobility, and developmental immaturity Teach toddlers to stay away from the street and provide constant supervision to prevent pedestrian injury. Require bicycle helmet use while riding any wheeled toy to prevent head injury and form habit of helmet use. Childproof the home to provide a developmentally safe environment for the curious and increasingly mobile toddler. Never leave a toddler unattended in a tub or pool or near any body of water to prevent drowning. Teach parents first-aid measures and child CPR to minimize consequences of injury should it occur. Provide close observation and keep side rails up on crib/bed in hospital because toddlers are at particularly high risk for falling. NURSING DIAGNOSIS: Imbalanced nutrition, less than body requirements, related to inappropriate nutritional intake to sustain growth needs (excess juice or milk intake, inadequate food variety intake) as evidenced by failure to attain adequate increases in height and weight over time Outcome Identification and Evaluation: Toddler will consume adequate nutrients while using an appropriate feeding pattern: Toddler will demonstrate weight gain and increases in height. Interventions: Assess current feeding schedule and usual intake, as well as methods used to feed, to determine areas of adequacy versus inadequacy. Determine toddler's ability to drink from cup, finger feed, swallow, and consume textures to determine if additional exposure is needed. Weigh toddler daily on same scale if hospitalized, weekly on same scale if at home, and plot growth patterns weekly or monthly as appropriate on standardized growth charts to determine if growth is improving. Wean from bottle by 15 months of age to discourage excess milk or juice intake in toddler who can carry bottle around. Limit juice and milk minimum per day to discourage sense of fullness achieved with excess milk or juice intake, thereby increasing appetite for solid foods. Provide three nutrient-dense meals and at least two healthy snacks per day to encourage adequate nutrient consumption. Feed toddler on a similar schedule daily, without distractions and with the family: toddlers respond well to routine and structure and may eat better in the social context of meals, and they become distracted easily (TV should be off). NURSING DIAGNOSIS: Interrupted family processes related to issues with toddler development, parental verbalization of difficulty with current situation, possible crisis related to health of family member other than the toddler Outcome Identification and Evaluation Family will demonstrate adequate functioning: Family will display coping and psychosocial adjustment. Interventions: Assess the family's level of stress and ability to cope to determine family's ability to cope with multiple stressors. Engage in family-centered care to provide a holistic approach to care of the toddler and family. Encourage family visitation and provide for sleeping arrangements for a parent or caregiver to stay in the hospital with the toddler (contributes to family's sense of control of situation). Involve family members in toddler's care, giving them a feeling of control and connectedness. QUESTIONS??? Summary Toddler's appetite is decreased so growth slows, but he still needs appropriate nutritional intake. Head circumference equal chest circumference in around 1 year. The psychosocial task of the toddler years is to attain a sense of autonomy. Toddler fear of animals , loud voice and strange persons and places. The toddler refines gross motor skills and fine motor skills. Toddler language is about fulfilling his needs and he can flow simple instructions. The toddler learn right from wrong in way to punishment avoidance. Toilet teaching can be achieved around 2 years of age when signs of readiness was appear. Toddler discipline should focus on clear limits and consistency. Close observation should provided because toddlers are high risk for falling. Limit juice and sweets to minimum per day to discourage to improve appetite to nutrients foods. Try to give family center care as possible.