Maternal and Child Health 2024-2025 PDF

The 1st level Dr. Lamiaa Gamal Elrashidy Lecturer of Maternal & Child Health Alexandria University 2024-2025 2  Chapter I The child growth & development  The child growth & development Health is a state of complete physical, mental and social well-...

The 1st level Dr. Lamiaa Gamal Elrashidy Lecturer of Maternal & Child Health Alexandria University 2024-2025 2  Chapter I The child growth & development  The child growth & development Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (World Health Organization) Healthy children live in families, environments, and communities that provide them with the opportunity to reach their fullest developmental potential. Who is a child? Childhood is understood in different ways around the world. For example, some cultures define adulthood not by age, but by onset of puberty. UN convention on the rights of the child defines a child as: “ Every human being below the age of 18 years unless under the law applicable to the child, majority is attained earlier” Stages of childhood: ▪ Early Childhood : Birth to Eight Years ▪ Middle Childhood: Eight to Twelve Years ▪ Adolescence: Twelve to Eighteen Years Other classification:  Fetus (prenatal) (Starts at conception, continues through implantation in the uterine wall by the embryo, and ends at birth.)  Newborn (1st 28 days after birth)  Infancy & toddlerhood (Starts after the 1st month and continues to two years of age)  Early childhood (Starts at two years of age until six years of age)  Middle and late childhood (Starts at six years of age and continues until the onset of puberty)  Adolescence (Starts at the onset of puberty until 18) 4  Stages of childhood Pregnancy )fetus) Neonate (birth- 1 month) Infancy (1 month – 2 y) Early childhood (2 y- 6y) Middle childhood (6-9 y) Late childhood (9-12 y) Adolescence (12-18 y) 5 Factors affecting the child health: Both nature and nurture affects the child health. The factors could be protective factors or risk factors. The biopsychosocial model for determining the factors: Biological factors: - Genetics: e.g., down syndrome, hemophilia, muscular dystrophy - Perinatal events (Prenatal / natal/ postnatal) ▪ Birth weight ▪ Maternal factors (diseases of pregnancy e.g., gestational diabetes, preeclampsia- medications, smoking, drug addiction- chronic diseases- nutrition [ folic acid, iron deficiency anemia, undernutrition and obesity]- maternal infections [ syphilis, toxoplasmosis, German measles….) - Sex of the child - Hormones (growth and thyroid hormones) - Nutrition - Temperament Psychological factors: - Behavioral beliefs and attitudes: healthy and unhealthy lifestyle e.g., oral hygiene, eating habits, breastfeeding, vaccination - Maternal depression - Overprotection and child abuse (physical, sexual, neglect) 6 Factors affecting the child health: Social factors: - Environmental factors: Infections Radiation: x-ray Toxins: lead, mercury Pollution Nutrition Housing - Social/ familial factors: Parent-child relationship Violence Parental education, employment Parental disability Family stress and trauma Marital status, family size - Economic factors: Poverty Availability and quality of health services Availability of recreational services (sport, arts, music…) 7  Genetics: Dominant traits: are guaranteed to appear in the offspring whenever they are present. Recessive traits: do not appear in the offspring when the opposite is present; They manifest themselves only in the absence of the opposite dominant trait when both parents carry it. Sex-borne traits are the traits carried by chromosomes that determine the sex of an individual. Therefore, it is only found in one sex. The internal environment: Intelligence: Children with high IQs have better growth and development in functional and social aspects. The internal environment: The hormonal effect: Growth hormone: Deficiency leads to dwarfism and the excess leads to gigantism. Thyroxine: Deficiency leads to dwarfism, and intellectual disability. Sex hormones and the hormones of the pituitary gland: The appearance of secondary sexual signs Other hormones: cortisol and insulin 8  Emotions: Relationships with other significant people, mother, father, siblings, peers, and teachers play a vital role in a child's emotional, social, and intellectual development. If the child is given the necessary care and love that promotes healthy growth, otherwise there is a delay in growth and development. Emotionally deprived children may receive adequate nutrition but not gain weight as expected and be pale and unresponsive. If emotional deprivation persists and loving care is not provided over a period of time, children may become ill, develop a communication disorder, or die at an early age. 9 The external environment: The methods of childbearing and infant feeding in society are determined by cultural customs. During periods of rapid growth such as prenatal, lactation, puberty and adolescence, a high amount of protein and calories is needed. Diseases and disorders that affect nutrition affect the growth and development of the child. Weight gains are the lowest in the summer and fall. The largest gains in height among children occur in the spring. The differences are mainly due to seasonal changes. Infections and injuries are common in hot, humid climates. Exercise, increases blood circulation, enhances physiological activity and stimulates muscle growth. The first child born in the family receives all parental attention until the birth of the second child. The parents of the first child are unusually inexperienced and may not know the successive stages of growth and development. An only child develops more quickly and intellectually than other children who have siblings. 10  The Childhood Development Early childhood covers the beginnings of human life from birth to eight or nine. It is the fastest developing stage in his life. Although every child grows and develops at a certain pace, this is done according to specific principles and stages, physically, mentally, and emotionally. Development is defined as the process of change through which a child attains mastery of increasingly complex levels of moving, thinking, feeling, and interacting with people and things in the environment around him. A child's development involves a gradual unfolding of biologically determined traits as well as characteristics that emerge as the child learns from experience. Physical development and mental and emotional development are of crucial importance in the overall development of the child (Myers, 1995). What do young children need to grow and develop? The first three years are the most important in a child's life. During this period, the brain is more resilient than at any other time, grows rapidly and is more responsive to the outside world. Neural pathways in the brain that support communication, cognition, social development and emotional well-being also grow rapidly in the first three years. One of the reasons for poor brain development is malnutrition. Children who were previously severely malnourished infants have poorer school performance than their peers. Their chances of doing productive work and building healthy relationships are also reduced, and they are more likely to suffer from physical and psychological illnesses. 11 However, the brain needs more than food in order to grow and develop well. Growth and development complement one another but are not identical: for example, if a child's muscles are not developing, he or she will not be able to develop the physical skills of running and playing. But if the child's muscles grow but no one plays with him, or we don't show him a way to play, he will not learn to play either. For children to grow and develop they need nurturing, responsiveness and stimulation. The environment in which a child grows is literally sculpting his brain. When a parent responds quickly to a child in a warm and affectionate way, the child learns that his or her needs will be met. He feels safe and loved. A child learns to communicate when his mother sings or talks to him before he can even speak. When the parent encourages the child's interest in the world and curiosity, the child seeks to learn more. All these activities are called stimulation. The lack of stimulation and the lack of quality in the care relationship that the child lives in at this critical stage of his life, will stop his emotional, social, physical and cognitive development. There is also evidence that if a child lives severe, recurrent or prolonged adversity without receiving the support of an adult, the prolonged exposure to psychological stress can affect the brain’s development. 12 Children's developmental needs: (for reading) What children can do What children need From birth to 3 months old Perceive the world around them Protection from physical dangers through all their senses Adequate nutrition (it is better if only Keep track of people and things with their mothers feed them) their eyes Adequate health care (immunization, Reaction to bright faces and colors providing the body with oral fluids, ensuring health conditions) Stretch out, touch and explore hands and feet Having an adult familiar to them Raise head and turn towards the Having an adult who can understand sources of the sounds their signals and respond to them Crying, but often be quieter when Things to see, touch, hear, smell and cuddling taste start smiling Pregnancy, singing and swinging Begin to develop a self awareness 4 to 6 months smiling a lot All the above, plus opportunities to Preference for parents and older explore the surrounding world relatives Adequate stimulation of expression Repeat the movements that interest language them Daily opportunities to play with a listen carefully variety of things Respond when talking to them Laughing, chirping, and imitation of sounds Exploring hands and feet Putting things in the mouth Sitting leaning on something, rolling over, stretching neck and rolling over Holding objects without using the 13 thumb Children's developmental needs:) for reading) What children can do What children need From 7 months to 12 months Remember simple events All the above, plus: Getting to know oneself, body parts Provide them with additional and familiar sounds supportive foods Realize their names, common words Provide opportunities to listen to and read other stories for them Pronunciation of the first words with meaning A safe environment to explore Explore, bang and shake things Find hidden things, put things into boxes sitting alone Crawling and getting up to standing and walking Show shyness or anxiety when meeting strangers From one to two years Imitating the actions of adults All of the above, plus: Helping to acquire new skills in Speaking and understanding words movement, language and thinking and ideas An opportunity to develop a measure Enjoy stories and experience using of independence things Help learn how to control their behavior Walking steady, climbing chairs and An opportunity to start learning how running to take care of themselves asserting their independence, but A chance to play and explore favoring people they are familiar with Playing with other children Realizing the ownership of things Take pride in getting things done Willingness to assist in carrying out Make friends tasks Problem Solving Start pretending to play Health care should also include Read or tell stories to them daily deworming, if necessary 14 Children's developmental needs: (for reading) What children can do What children need From two years to 3 and a half years Enjoy learning new skills All the above, plus: Learn the language quickly Make choices Always ready to go out Participation in pretend games Gaining the ability to control hands Sing your favorite songs and fingers Solve simple puzzles Get frustrated easily Representing familiar situations Acting more independently, while still being dependent on others A child's developmental needs vary during the first years of life according to each child's maturation process. Therefore, the programs will have different focus points regarding the developmental status of the child. At the very least, the following periods can be distinguished: Prenatal to neonatal period. The focus during this period is on the mother through maternal and child health programs, and through parental support and education. Childhood (up to approximately eighteen months). Focus during this period on health and nutrition. Breastfeeding is critically important; Every effort should be made to keep the child at the mother's side. The central tasks appear to be sensory learning, particularly auditory and visual, control of physical movements, and association with a primary custodian. The stage of learning to walk and beyond (from about eighteen to thirty- six months). Nutrition remains of vital importance during this period. A child's coordination, language, reasoning ability and social skills develop 15 rapidly. Development or growth refers to the stability and change in the vital functional characteristics of humans over a lifetime and across generations. (Bronfenbrenner and Morris, 1998) Development is the gradual and orderly change in behavior and activities that we observe as children grow up. Their physical ability and understanding of the world around them increases and matures with age. A healthy nervous system and a safe and stimulating environment are needed for normal development, as well as normal hearing and vision. Growth areas: Physical growth: changes in body size, proportions, appearance, functioning of various body systems, brain development, cognitive and motor abilities, and physical health. Cognitive development: developing a variety of thinking processes and intellectual abilities, including language, attention, memory, learning, academic skills, problem-solving, imagination and creativity Emotional and social development includes processes related to an individual's interaction with others, including emotional communication, self- understanding, ability to manage feelings, knowledge of others, interpersonal skills, personality, friendships, intimate relationships, moral thinking and behavior Critical Issues in Growth Theories: ▪ Nature vs. nurture ▪ critical and sensitive periods ▪ Comprehensiveness vs. context specific ▪ Individual differences 16 1. Nature and nurture: Nature: innate, biological influences, genetics, genes Nurture: the influence of the environment, physical and social factors on growth. Most theories see a complex interaction between both that affects the growth and development of the child 2. Critical and sensitive periods: Critical period: the time during which a specific biological or environmental event must occur for development to proceed (for example, visual processing). Sensitive period: the optimal time to develop specific behaviors or functions but is not dependent on it. 3- Comprehensiveness vs. context specific: Comprehensiveness: Children everywhere follow the same path of development Context specific: children grow up in distinct contexts with unique physical, social, cultural, economic and historical conditions that lead to different paths of development 4- Phenomena of individual differences: Genetic and epigenetic differences (environmental influence on genes) Differences in children's experiences (for example, how parents treat children) Different influences on children from similar experiences (e.g., loss, foster care, etc.) Children's choice of environments 17 What are the principles of development? ▪ A continuous process in which new skills are acquired ▪ An indicator of the maturity of the central nervous system ▪ Involuntary movements stimulate the emergence of voluntary movements ▪ It starts from the head and from the nearby joints: Development follows a specific pattern and sequence Such as - from head down - From the center to the extremities - From the near to far ▪ It evolves from dependence to independence ▪ Development proceeds from general to specific. ▪ Growth and development is a product of both heredity (nature) and environment (nurture). ▪ Development is Predictable ▪ There is a Constant Interaction Between All Factors of Development: 18 ▪ Development in one area is highly related to development in other areas. For example, a child who has a good health can be active socially and intellectually. How is the development monitored? Developmental milestones are used to monitor development in childhood. These are easily observable developmental achievements such as smiling, sitting and walking. Milestones are assessed by both history and examination. The developmental monitoring of milestones must be part of the routine growth and developmental screening of all children. The formal assessment of development is often divided into: ▪ Gross motor development (locomotion) ▪ Fine motor development (manipulation of objects) ▪ Language and communication (using sounds and words) ▪ Personal and social development (relating to family and society) What are normal milestones? Developmental milestones are largely predictable as children get older although there is a range between different normal children. Delayed milestones are warning signs that neurodevelopment may be abnormal. Children with delayed milestones should be referred for formal developmental assessment. 19 The following milestones should be achieved: ▪ Smile at mother: 8 weeks ▪ Good head control: 6 months ▪ Sit unsupported: 9 months ▪ Crawl well: 12 months ▪ Make babbling noises (‘baby sounds’): 12 months ▪ Stand without help: 15 months ▪ Walk without help: 18 months ▪ Understand simple commands: 24 months ▪ Use one or two words: 36 months Normally developing children should reach these milestones before (often long before) these cut-off ages. Several formal screening tools are used to monitor development. The Denver Developmental Screening Test is commonly used in children from birth to 6 years of age. Other developmental screening tools include parent completed Ages and Stages Questionnaires, and Parents’ Evaluation of Developmental Status. Language and cognitive development is often screened at school, e.g., ‘IQ’ testing. 20 Developmental domains from birth through 6 years old: (for reading) AGE GROSS MOTOR FINE MOTOR– PERSONAL LANGUAGE OTHER ADAPTIVE -SOCIAL COGNITIVE 2 wk Moves head side Regards face Alerts to bell to side 2 mo Lifts shoulder Tracks past Smiles Cooing while prone midline responsively Searches for sound with eyes 4 mo Lifts up on hands Reaches for Looks at hand Laughs and object squeals Rolls front to back Begins to Raking grasp work toward If pulled to sit toy from supine, no head lag 6 mo Sits alone Transfers object Feeds self Babbles hand to hand Holds bottle 9 mo Pulls to stand Starting to pincer Waves bye- Says Dada grasp bye and Mama, Gets into sitting but position Bangs two blocks Plays pat-a- nonspecific together cake Two-syllable sounds 12 mo Walks Puts block in cup Drinks from a Says Mama cup and Dada, Stoops and stands specific Imitates others Says one to two other words 15 mo Walks backward Scribbles Uses spoon Says three to and fork six words Stacks two blocks Helps in Follows housework commands 18 mo Runs Stacks four Removes Says at least blocks garment six words Kicks a ball “Feeds” doll 21 Developmental domains from birth through 6 years old: (for reading) AGE GROSS FINE PERSONAL- LANGUAGE OTHER MOTOR MOTOR– SOCIAL COGNITIV ADAPTIVE E 2 yr Walks up and Stacks six Washes and Puts two words Understands down stairs blocks dries hands together concept of Throws Copies line Brushes teeth Points to today overhand pictures Puts on clothes Knows body parts 3 yr Walks steps Stacks eight Uses spoon Names pictures Understands alternating blocks well, spilling Speech concepts of feet little Wiggles thumb understandable tomorrow Broad jump Puts on T- to stranger 75% and shirt Says three-word yesterday sentences 4 yr Balances well Copies O, Brushes teeth Names colors on each foot maybe + without Understands Hops on one Draws person help adjectives foot with three Dresses parts without help 5 yr Skips Copies Counts Heel-to-toe Understands walks opposites 6 yr Balances on Copies Δ Defines words Begins to each foot 6 Draws person understand sec with six parts right and left Mo, Month; sec, second; wk, week; yr, year 22 The primitive reflexes present at birth gradually disappear as postural reflexes develop, which are essential for independent sitting and walking. Moro – sudden extension of the head causes symmetrical extension, then flexion of the arms Grasp – flexion of fingers when an object is placed in the palm Rooting – head turns to the stimulus when touched near the mouth Stepping response. – stepping movements when held vertically and dorsum of feet touch a surface Asymmetrical tonic neck reflex. – lying supine, the infant adopts an outstretched arm to the side to which the head is turned Postural reflexes: Labyrinthine righting. – head moves in opposite direction to which the body is tilted Postural support. – when held upright, legs take weight and may push up (bounce) Lateral propping. – in sitting, the arm extends on the side to which the child falls as a saving mechanism Parachute – when suspended face down, the arms extend as though to save themself 23 Physical growth in infants and children: Physical growth refers to the increase in body size (length or height and weight) and in the size of organs. Children grow rapidly from birth until the child is one or two years old. Growth slows after a child reaches this age. Growth in height and weight is consistent throughout the preschool and school years. Children tend to grow in equal amounts annually until the next major growth spurt occurs in early adolescence. However, the rate of growth varies with different organs; For example, the reproductive system has a short growth spurt soon after birth, and changes are minimal even before sexual maturity (puberty). In contrast, brain development is nearly limited in the early years of life. The kidneys function similarly to those of adults when they are completed. The child is in his first year. Doctors record the children's growth and compare it to other children of the same age and monitor the children's weight gain relative to their height. From birth to five years of age, doctors record all growth indicators on a graph using the standard growth charts from the World Health Organization. (WHO). Length and Height: Very young children are measured before they can stand while lying on their back on a suitable device, such as a stadiometer. In children who can stand, height is measured using a vertical measuring scale. Infants usually grow about 25 cm during the first year and by five years of age they are twice their height at birth. In boys, they are half the height of adults when they are about two years old. In girls, when they are 19 months old, they reach about half their adult height. 50 cm At birth 75 cm At 1st year 100 cm At 4 years 24 The weight: Full-term newborns typically lose 5-8% of their birth weight within the first few days of life. And regain this weight by the end of the first two weeks. After this period, newborns gain about thirty grams per day during the first two months, and about half a kilogram per month after that. This weight gain usually results in a doubling of birth weight by 5 months of age and a tripling of birth weight by the time the infant is one year old. The proportion of children who are obese has increased in recent years. Some children become obese at an early age. weight At birth 3 kg Double weight At 4 6 kg months Triple weight 9 kg At one year 25 Head circumference: The head circumference is the circumference of the largest area of ​the child's head. Doctors place the measuring tape above the eyebrows, ears, and around the back of the head. This measurement is necessary because the size of the head reflects the size of the brain, and this measurement allows doctors to see if a child's brain is growing at a normal rate. The circumference of the head is routinely measured until children are 3 years old. At birth, the brain volume is equivalent to 25% of the brain volume of a future adult, and the head circumference measures about 35 centimeters. At one year of age, the brain is 75% of that of an adult’s brain. At 3 years of age, the brain is 80% of its adult size. At 7 years of age, the brain is 90% of its size in an adult. 35 cm At birth 45 cm At one year 50 cm At 5 years 55 cm At 12 years the teeth: The timing of tooth eruption varies mainly for genetic reasons. However, tooth eruption may also be delayed due to disorders such as: rickets, hypopituitarism, hypothyroidism, or down syndrome. The lower front teeth usually begin to erupt between 5-9 months of age. The upper front teeth begin to erupt between the ages of 8-12 months. On average, infants have 6 teeth by 12 months of age, 12 teeth at 18 months of age, 16 teeth by 2 years of age, and all of their 20 deciduous teeth by 2½ years. Milk teeth are replaced by permanent teeth (such as adults) when they are 5-13 years old. Permanent teeth tend to erupt at an earlier age in girls. 26 Importance of Growth Monitoring: What is growth monitoring? Growth monitoring is the regular measurement of a child's size in order to document growth. The child's size measurements should then be plotted on a growth chart. This is very important as it can detect early changes in a child's development. Growth that is too slow or too fast may indicate a nutritional or other health problem. Therefore, growth monitoring is an essential part of children's primary health care. A baby size measurement is of very little value unless it is used to monitor growth. What is the value of weight in growth monitoring? Weight-for-age is commonly used to monitor growth. It is especially useful in young infants who usually gain weight quickly. A normal weight gain indicates that the infant is healthy and growing normally. Failure to gain weight is often the first sign of illness or malnutrition (i.e. nutritional deficiencies). Therefore, the child should be weighed at each clinic visit in order to monitor growth. What is the value of the measurement of height and head circumference? These are also important measures of growth. Height is the best way to measure linear growth (stature) as height reflects growth over a longer period than weight does. Therefore, measuring height is important in older children. Head circumference can be used to assess brain development in children under two years of age. During this period, brain development is rapid, and therefore the head circumference increases rapidly. A small head (microcephaly) indicates a small brain, while a large head indicates hydrocephalus. Head circumference is less accurate in assessing brain development over the age of 2 years. Therefore, measuring head circumference is very useful for young children and height in older children. If the child's weight gain is normal, the height and head circumference are usually also normal. However, it is especially important to measure height and head circumference in children who are not gaining weight normally. 27 Can an infant's growth be determined in a one-time visit to the pediatrician? No, because the definition of growth is a change in body size over a period. Therefore, another form of growth assessment is required when you cannot wait a few weeks or months to decide whether a child is growing normally. A growth assessment may be done if the child's size is compared to that of other children of the same age. In order to do this, the normal range (i.e., average size) is needed for children of this age. If the baby is the same size as most other babies of the same age, the baby is likely growing normally. The most used growth charts are the percentile charts. 28 29 Chapter II Nutrition 3 0 Breastfeeding  Breastfeeding Breastfeeding gives children the best start in life. It is estimated that over one million children die each year from diarrhea, respiratory and other infections because they are not adequately breastfed. Many more children suffer from unnecessary illnesses that they would not have if they were breastfed. Breastfeeding also helps to protect mothers' health. The World Health Organization and UNICEF recommend exclusive breastfeeding from birth for the first 4-6 months of life, and sustained breastfeeding together with adequate complementary foods up to 2 years of age or beyond. WHY BREASTFEEDING IS IMPORTANT? Breast milk: ▪ Perfect nutrients ▪ Easily digested, efficiently used ▪ Protect against infections ▪ Costs less than artificial feeding Breastfeeding: ▪ Helps bonding and development Breastfeeding helps a mother and baby to form a close, loving relationship, which makes mothers feel deeply satisfied emotionally. Close contact from immediately after delivery helps this relationship to develop. This process is called bonding. Babies who are breastfed have higher IQ scores and better jaw development. ▪ Helps delay a new pregnancy ▪ Protects mother’s health (against cancer [breast and ovarian], bleeding, depression) ▪ Breastfeeding lowers the risk of being overweight, obesity and diabetes in childhood and adulthood. 32  Cheap Sterile Available at any time In suitable Easy to prepare temperature Protective against Stored in perfect breast and ovarian temperature The mother cancer Improving the child The baby Reduce the immunity postpartum bleeding The amount is Psychological support according to the Contraception infant’s need Contains growth factors Psychological support 33 Variations in the composition of breastmilk: Colostrum is the breastmilk that women produce in the first few days after delivery. It is thick and yellowish or clear in color. (its importance is antibody, growth factors and vitamin A rich. So, it helps against infections, allergy, and prevents jaundice) Mature milk is the breastmilk that is produced after a few days. The quantity becomes larger, and the breasts feel full, hard and heavy. Some people call this the breastmilk `coming in'. Foremilk is the milk that is produced early in a feed. Hindmilk is the milk that is produced later in a feed. RECOMMENDATIONS ▪ Start breastfeeding within 1 hour of birth ▪ Breastfeed exclusively from 0-6 months of age ▪ Complementary foods can begin between 4-6 months (exact age varies) ▪ Give complementary foods to all children from 6 months of age ▪ Continue breastfeeding up to 2 years of age or beyond TERMS FOR INFANT FEEDING Exclusive breastfeeding: Exclusive breastfeeding means giving a baby no other food or drink, including no water, in addition to breastfeeding (except medicines and vitamin or mineral drops; expressed breastmilk is also permitted). Bottle feeding: Bottle feeding means feeding a baby from a bottle, whatever is in the bottle, including expressed breastmilk. Artificial feeding: Artificial feeding means feeding a baby on artificial feeds, and not breastfeeding at all. Partial breastfeeding: Partial breastfeeding means giving a baby some breastfeeds, and some artificial feeds, either milk or cereal, or other food. 34 HOW BREASTFEEDING WORKS? Prolactin hormone: secreted after feed to produce the next feed, more prolactin secreted at night, suppresses the ovulation. Oxytocin hormone: works before and during the feed to make milk flow. It makes uterus contract. BREASTFEEDING WILL BE SUCCESSFUL IN MOST CASES IF: The mother feels good about herself The baby is well attached to the breast so that he suckles effectively The baby suckles as often and for as long as he wants The environment supports breastfeeding Storage of breast milk: 4–8 hours in room temperature 3 days in refrigerator 3-6 months in the freezer (-18 c) 35  Signs that Signs of possible breastfeeding is going difficulty well BODY POSITION Mother relaxed and Shoulders tense, leans comfortable over baby Baby's body close, Baby's body away from facing breast mother's Baby's head and body Baby's neck twisted straight Baby's chin not touching Baby's chin touching breast breast [Only shoulder or head [Baby's bottom supported] supported] RESPONSES Baby reaches for breast No response to breast if hungry [No rooting observed] [Baby roots for breast] Baby not interested in Baby explores breast breast with tongue Baby restless or crying Baby calm and alert at Baby slips off breast breast No signs of milk ejection Baby stays attached to breast Signs of milk ejection, [leaking, afterpains] EMOTIONAL Secure, confident hold Nervous or limp hold BONDING Face-to-face attention No mother/baby eye from mother contact Much touching by Little touching or mother Shaking or poking baby 36  Signs that Signs of possible breastfeeding is going difficulty well ANATOMY Breasts soft after feed Breasts engorged Nipples stand out, Nipples flat or inverted protractile Fissures or redness of Skin appears healthy skin Breast looks round Breast looks stretched or during feed pulled SUCKLING Mouth wide open Mouth not wide open, points forward Lower lip turned outwards Lower lip turned in Tongue cupped around Baby's tongue not seen breast Cheeks are tense or Cheeks are round pulled in More areola above More areola below baby's mouth baby's mouth Slow deep sucks, bursts Rapid sucks only with pauses Can hear smacking or Can see or hear clicking swallowing TIME SPENT Baby releases breast Mother takes baby off SUCKLING breast Baby suckled for 5-40 minutes 37 The dangers of prelacteal feeds: Prelacteal feeds are artificial feeds or drinks given to a baby before breastfeeding is initiated. They are dangerous because: They replace colostrum as the baby's earliest feeds. - The baby is more likely to develop infections such as diarrhea, septicemia and meningitis; - He is more likely to develop intolerance to the proteins in the artificial feed, and allergies, such as eczema. They interfere with suckling. - The baby's hunger is satisfied, so that he wants to breastfeed less. - If he is fed from a bottle with an artificial teat, he may have more difficulty attaching to the breast, (sucking confusion, or nipple confusion). - The baby suckles and stimulates the breast less. - Breastmilk takes longer to `come in' and it is more difficult to establish breastfeeding. POSITIONING A BABY AT THE BREAST: ▪ The baby's head and body should be in a straight line. ▪ His face should face the breast, with his nose opposite the nipple. ▪ His mother should hold his body close to hers. ▪ If her baby is newborn, she should support his bottom, and not just his head and shoulders. Positions of breastfeeding: 1- the cradle position 2- the cross-cradle position Useful for: very small babies - sick babies 3- the football holding position: Useful for: twins - blocked duct - difficulty attaching the baby 4- the lying down position 5- laid back hold 38 Signs of good suckling attachment are ▪ The baby’s chin touches the breast ▪ His mouth is wide open ▪ His lower lip is turned outwards ▪ One can see more of the areola above his or her mouth and less below. Good attachment Bad attachment 39 BREAST CONDITIONS: There are several common breast conditions which sometimes cause difficulties with breastfeeding: - Flat or inverted nipples, and long or big nipples; - Engorgement; - Blocked duct and mastitis; - Sore nipples and nipple fissure. Diagnosis and management of these breast conditions are important both to relieve the mother, and to enable breastfeeding to continue. MANAGEMENT OF FLAT AND INVERTED NIPPLES: Antenatal: treatment Probably not helpful Soon after delivery: Build mother's confidence - breasts will improve Explain baby suckles BREAST not nipple Let baby explore breast, skin-to-skin Help mother to position baby early Try different positions - e.g., underarm Help her to make nipple stand out more Use pump, syringe For first week or two: Express breastmilk and feed with cup if necessary Express breastmilk into baby's mouth SUMMARY OF DIFFERENCES BETWEEN FULL AND ENGORGED BREASTS ▪ FULL BREASTS: Hot Heavy, Hard, Milk flowing, No fever ▪ ENGORGED BREASTS: Painful, edematous, Tight, especially nipple, Shiny May look red, Milk NOT flowing, May be fever for 24 hours 40 TREATMENT OF BREAST ENGORGEMENT (Do not "rest" the breast) ▪ If baby able to suckle: Feed frequently, help with positioning. ▪ If baby not able to suckle: Express milk by hand or with pump ▪ Before feed to stimulate oxytocin reflex: Warm compress or warm shower, Massage to neck and back, Light massage of breast, Stimulate nipple skin, Help mother to relax ▪ After feed to reduce oedema: Cold compress on breasts 41 WHY A BABY MAY REFUSE TO BREASTFEED? 1. Is the baby ill, in pain or sedated? Illness: The baby may attach to the breast but suckles less than before. Pain: Pressure on a bruise from forceps or vacuum extraction. Blocked nose: Sore mouth (Candida infection (thrush), an older baby teething). Sedation: A baby may be sleepy because of: - drugs that his mother was given during labor; - drugs that she is taking for psychiatric treatment. 2. Is there a difficulty with the breastfeeding technique? Bottle feeds, dummies technique Not getting much milk (poor attachment, engorgement) Pressure on back of head when positioning Mother shaking breast Restricting feeds Oversupply of breastmilk Difficulty coordinating suckle 3. Has a change upset the baby? This is commonest when a baby is aged 3-12 months. He suddenly refuses several breastfeeds. This behavior is sometimes called a `nursing strike'. Possible causes: - Separation from his mother, for example when she starts a job. - A new carer, or too many caregivers. - A change in the family routine - for example, moving house, visiting relatives. - Illness of his mother, or a breast infection. - His mother menstruating. - A change in his mother's smell, for example, different soap, or different food 4. Is it `apparent' and not `real' refusal? Sometimes a baby behaves in a way which makes his mother think that he is refusing to breastfeed. However, he is not really refusing. - When a newborn baby `roots for the breast, he moves his head from side to side as if he is saying `no'. However, this is normal behavior. - Between 4 and 8 months of age, babies are easily distracted, for example when they hear a noise. They may suddenly stop suckling. It is a sign that they are alert. - After the age of 1 year, a baby may wean himself. This is usually gradual. 42 SIGNS THAT A BABY MAY NOT BE GETTING ENOUGH BREASTMILK ______________________________________________________________ RELIABLE Poor weight gain (Less than 500 g a month)(Less than birth weight after 2 weeks) Passing small amount (Less than 6 times a day, of concentrated urine yellow and strong smelling) ______________________________________________________________ POSSIBLE Baby not satisfied after breastfeeds Baby cries often Very frequent breastfeeds Very long breastfeeds Baby refuses to breastfeed Baby has hard, dry or green stools No milk comes when mother tries to express Breasts did not enlarge (during pregnancy) Milk did not `come in' (after delivery) 43 REASONS WHY A BABY MAY NOT GET ENOUGH BREASTMILK Breastfeeding factors: Delayed start, Infrequent feeds, No night feeds, Short feeds, Poor attachment. Bottles, pacifiers Complementary feeds Mother: psychological factors: Lack of confidence, Worry, stress, Dislike of breastfeeding, Rejection of baby, Tiredness Mother: physical condition: Contraceptive pills Pregnancy Severe malnutrition Alcohol Smoking Baby's condition: Illness Abnormality 44 CONTRAINDICATIONS OF BREASTFEEDING: Medical Contraindications for Breastfeeding There are few true medical contraindications to breastfeeding – Infant with classic galactosemia – Mother living with human immunodeficiency virus (HIV) (developed countries) Maternal Conditions Where Breastfeeding is Not Advisable but Expressed Breastmilk Can Be Provided Untreated, active tuberculosis (‫)الدرن أو السل النشط‬ – Breastfeeding may resume after a minimum of 2 weeks of treatment and mother is determined not to be infectious Varicella (‫)الجديرى المائ‬ – Breastfeeding may resume once all lesions have become scabbed and crusted, and mother does not have any new vesicles appearing Active herpetic lesions on breast(s) (‫فيوىس‬ ‫)الهربز داء ر‬ – Avoid breastfeeding until all lesions healed – Breastfeeding may continue with the unaffected breast Maternal Conditions Where Temporary Cessation of Breastfeeding is Recommended and Expressed Breastmilk Should Not be Used: Specific Medications – e.g., Taking radioactive isotopes, cancer chemotherapy – Risks and benefits should be discussed for each Radiation Treatments ‫ى‬ Hepatitis C infection (‫الوبائ ىس‬ ‫)االلتهاب الكبدى‬ – If nipples/areola are cracked or bleeding – Once completely healed, can breastfeed or use expressed breastmilk Mothers with illegal drugs 45  Formula feeding Types of formula feeding: - Powder: least expensive, need water - Liquid concentrate: more expensive, need water - Ready to feed: use as is, most expensive There are also different types of milk e.g., first milk, second milk, follow–on milk, etc. First milks These milks are often described as for newborns. They are based on the whey of cow’s milk and are more easily digested than the other milks. If bottle–feeding, first milk is the only food your baby needs for the first six months. After six months continue to give first milk as you start to introduce solid food. When your baby is one year old, ordinary (full–fat) cow’s milk can be given. Second milks These are often described as for ‘hungrier babies. They are based on the curd of cow’s milk and take your baby longer to digest than first milks. They are not recommended for young babies. Follow–on milks Follow–on milks are described as suitable for babies from six months of age. It is not necessary to move your baby on to these milks. Follow–on milks should never be used for babies under six months old as they are not nutritionally suitable. Special formulas: - Lactose free milk: in cases of lactose intolerance and galactosemia - Phenylalanine free milk: in cases of phenylketonuria - Hypoallergenic milk: in cases of milk protein allergy - Soya formula: in cases of cow’s milk allergy, galactosemia, lactose intolerance - Reflux formulas are pre-thickened with rice starch. - Formulas for premature: for preterm babies < 37 weeks of gestation 46 Complementary feeding Complementary feeding is defined as the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk. Starting at six months, complementary food should be added to the child’s diet to complement the nutrients in breast milk. Breast milk alone cannot supply all the nutrients a baby needs at this stage of growth. (The term ‘weaning’ is no longer used, as it was commonly understood to mean cessation of breastfeeding.) The complementary feeding period is defined as starting at 6 months through to 24 months of age, even though breastfeeding may continue beyond two years. Complementary Food Timetable for Children 6 + months: How WHEN WHAT TEXTURE Breast Feeding Often First 2 No change, Vegetables 1-2 times Puréed/ weeks after feed on /fruit/rice per day Mashed 6 months demand Vegetables 3-4 weeks /fruit/meat/c 2-3 times Lumpy Reduced by 1 after 6 ereals/ per day Puréed time months cheese/ yoghurt 9- 12 months of Mashed Wide variety 3 times with fork 3-4 times/ day age of foods per day /finger food Above 12 Same food as Chopped or 3 times months of the family is pulsed/ 2-3 times/ day per day age eating finger food 47 The child nutrition Food groups: ▪ Grains ▪ vegetables ▪ fruit ▪ Meat & fish ▪ Fat ▪ Milk products Food elements and their importance: Carbohydrates: Source of energy Lipids: Source of concentrated energy Vitamins: Control vital reactions in the body Minerals: Control vital reactions in the body and enters in the formation of the body tissues Water: Control body temperature, and control the vital reactions in the body The food pyramid is a graphical representation, in the form of a triangle, of nutritional standards. It indicates the quantities and types of food needed daily to maintain the health status and to prevent or reduce the risk of development of eating disorders. 49 The food pyramid gives instructions on the amount of food to be eaten, how to avoid fatty foods, how to mix between different types of food and at the same time maintain health and fitness and avoid weight gain and obesity. A food pyramid is a triangle that contains lists of many foods. The more the pyramid goes to the top, the foods are less healthy and indicates a reduction of them. Healthy eating is about getting the right amount of nutrients - proteins, fats, carbohydrates, vitamins and minerals that you need to maintain your good health. Principles of Healthy Eating: Eat a variety of food and avoid picky eating Eat most - grains Eat more - fruits and vegetables Eat moderately - milk and alternatives, meat, fish, egg and alternatives (including dry beans) Eat less - fat/oil, salt and sugar Drink an adequate amount of fluid (including water, tea, clear soup, etc.) every day Have regular meals The combination of a healthy diet and regular physical activity can maintain a healthy body weight, thus benefiting our health and preventing diet-related diseases such as hypertension, heart disease, stroke, osteoporosis and cancer. 51 52 53 54 55  Malnutrition: The World Health Organization (WHO) defines malnutrition as "the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions." Malnutrition is a broad term commonly used as an alternative to under nutrition but technically it also refers to over nutrition. People are malnourished if their diet doesn’t provide adequate calories and protein for growth and maintenance, or they are unable to fully utilize the food they eat due to illness (under nutrition). They are also malnourished if they consume too many calories (over nutrition). (UNICEF) Physical signs Type I nutrient deficiency - Anemia ( iron) - Beri beri ( thiamin) - Pellagra (niacin) Growth failure - Xerophthalmia ( vit A) Under Micronutrient Malnutrition nutrition malnutrition reduced overall growth Over nutrition Mixed Type II nutrient Nitrogen, Sulphur, deficiency Essential amino acids, Potassium , Sodium, Magnesium, Zinc, Phosphorus 56  Acute malnutrition wasting or nutritional edema Chronic malnutrition Under nutrition Growth failure stunting / poor cognitive development Acute and /or chronic Micronutrient malnutrition malnutrition underweight Clinical forms of acute malnutrition: There are 3 clinical forms of acute malnutrition. Marasmus – severe weight loss or wasting Kwashiorkor – bloated appearance due to water retention (bilateral oedema). Marasmus-kwashiorkor – a combination of both wasting and bi-lateral oedema. Marasmus: ❑ A rapid deterioration in nutritional status in a short time can lead to marasmus, one form of acute malnutrition. ❑ Marasmus is the most common form of acute malnutrition in nutritional emergencies and, in its severe form, can very quickly lead to death if untreated. ❑ It is characterized by severe wasting of fat and muscle which the body breaks down to make energy. ❑ Wasting can affect both children and adults. the child at risk for: ▪ Hypoglycemia ▪ Hypothermia ▪ Fluid overload/ heart failure ▪ Infection A wasted child can be classified as either moderately or severely acutely malnourished based on body measurements. 57 Kwashiorkor Kwashiorkor is characterized by bilateral pitting oedema (affecting both sides of the body) in the lower legs and feet which as it progresses becomes more generalized to the arms, hands and face. Oedema is the excessive accumulation of fluid in body tissues which results from severe nutritional deficiencies. All cases of kwashiorkor are classified as severe acute malnutrition. Kwashiorkor is classified by the severity of the oedema, as follows: ❑ + Mild: both feet ❑ ++ Moderate: both feet, plus lower legs, hands or lower arms ❑ +++ Severe: generalized oedema including both feet, legs, hands, arms and face. Causes of malnutrition: Immediate causes: ▪ Reduced dietary intake ▪ Reduced absorption of macro- and/or micronutrients ▪ Increased losses or altered requirements ▪ Increased energy expenditure (in specific disease processes) Underlying causes: ▪ food insecurity ▪ inadequate care and poor public health Basic causes: ▪ Political, legal and cultural factors The children at significant risk for the development of nutritional deficiencies: ▪ Prematurity ▪ Developmental delay ▪ In utero toxin exposure (i.e., fetal alcohol exposure) ▪ Children with multiple food allergies present a special nutritional challenge because of severe dietary restrictions. ▪ Children with chronic illness 58 Who is vulnerable to under nutrition? - Groups vulnerable to under nutrition typically include those with increased nutrient requirements: children, pregnant and lactating women. - However, risk of under nutrition is related to more than just physiological vulnerability. Groups within the population can be at risk of under nutrition due to geographical vulnerability (displaced populations, inaccessible populations) as well as political vulnerability (minority groups). - Older people, the disabled, people with chronic illness and People living with HIV and AIDS Assessment: ✓ Anthropometry: It implies assessing the attainment of growth based on measures of physical characteristics of the body (e.g., weight, height, etc.) ✓ Biochemical tests: Assessing specific components of blood and urine samples of an individual. ✓ Clinical signs: Assessing signs and symptoms of illness (e.g., oedema). ✓ Dietary intake: Assessing food intake of individuals over a specific period in order to determine whether the quantity or quality of intake is adequate. Nutritional indices: Nutritional index Use Weight for height or length (WFH) an index used to measure wasting or acute malnutrition Height for age (HFA) an index used to measure stunting or chronic malnutrition Weight for age (WFA) an index used to measure underweight 59 Prevention against malnutrition: Maternal care Breastfeeding Supplements Immunizations Growth and School diet and development physical activity monitoring Hygiene and medical care 60 61  Chapter III Childhood safety 6 2  Personal hygiene and Infection Objectives: 1. To know the basics of personal hygiene 2. To recognize the infection cycle 3. To become familiar with the programs for the prevention of infectious diseases 4. To know examples of infectious diseases 5. To know the vaccination program for children in Egypt Hygiene Environmental hygiene Personal hygiene Health education for Food hygiene Place hygiene Regular checkup child and family Personal hygiene: The best means for the protection of children from infectious and communicable diseases e.g., diarrhea, typhoid, cholera, hepatitis A and the skin diseases that happened due to neglect of personal hygiene. Personal hygiene is defined as a group of practices that are associated with our everyday activities and related to hygiene for keeping health and a healthy lifestyle. So, we should promote these healthy behaviors and habits: First: skin hygiene: The skin is the outer part of the body, and it is the largest part of the outer body, so it is exposed to various types of dirt and germs in the air or through contact. It is necessary to refer here that the accumulation of dead cells and sweat on the surface allow increasing the chance of germs’ persistence and occurrence of skin infections and inflammation. Routine practices of skin hygiene: 1- Taking a shower regularly using warm water and soap, with the necessity of rubbing the skin well and increasing the number of showers in the summer and when sweating, as bathing stimulates blood circulation, and maintains hygiene and skin safety. 2- Washing the face frequently with soap and water, with a good scrub, at least twice a day. To get rid of sebum and dirt that is stuck in the face to prevent the appearance of pimples and acne. 3- Changing the underwear daily, and keeping the outer clothes clean, and washing them constantly. 4- Not to use the personal tools of others, as it is necessary for each person to have his towel to prevent the transmission of infectious skin diseases from one person to another. 63 Second: hair hygiene: Hair covers the human body in different parts thickly, such as the head, genital areas, and underarms, or lightly, such as the abdomen, chest, upper and lower extremities, and to maintain the cleanliness of the hair, the following must be considered: 1- Washing the hair regularly, periodically and whenever needed, using warm water, soap, and/or shampoo, as not paying attention to the cleanliness of the hair causes the accumulation of fat on it; Which leads to depriving it of the required nutrients to keep it strong and healthy, and the hair must be combed daily because this helps to stimulate blood circulation and thus strengthen the hair. 2- Cutting the hair periodically using clean tools, the longer the periods between hair cutting times leads to weak hair, especially if it is long, as it is necessary to get rid of dry dead hair at the ends. 3- Clean the hair under the armpits with soap and water. Removing the hair in this area decreases the possibility of itching and fungal infection. Third: hands hygiene: Germs do not need cars or planes to move from one place to another, but rather them; transmission through hands, which transfer bacteria, viruses, fungi, and parasites from one person to another or, to the person himself directly or through an intermediary, so hand hygiene is one of the most important measures that prevent the transmission of diseases to the body, and to maintain clean hands, you must follow these measures: 1- Wash hands thoroughly using soap and water; to get rid of germs attached to them and to prevent the transmission of infectious diseases, especially: Before and after eating After using the bathroom (toilet) Before and after visiting or caring for a patient Before bed and after waking up. After touching contaminated surfaces (such as trash and unclean clothes) After sneezing or coughing 64 2- Duration of washing hands: between 20-40 seconds 3- Washing hands with soap and water after touching animals to prevent infection with diseases that are transmitted from animal to human, as it is preferable that animals not enter homes. 4- Trim the nails regularly and in a proper manner (circularly trimming the fingernails to prevent the nails from growing under the skin), considering the cleaning under the nails to prevent the accumulation of dirt and germs. Fourth: the feet hygiene: During the day, people are often wearing socks and shoes, and this makes foot care very important so that germs and fungi do not reach between the toes. As well as to prevent infection with infectious diseases such as fungi or infections between the fingers, and because the feet remain for a long time not exposed to the air, they must be well taken care of, through: 1- Washing the feet with soap and water after removing the shoes and socks, taking care to dry them well, especially between the toes, to prevent the growth of fungi. 2- Trim the nails in the right way (horizontally) and continuously to prevent the nails from growing under the skin, and the appropriate time to trim the nails is after taking a shower because they are soft, considering keeping them clean to prevent dirt from collecting under them. 3- It is preferable to wear cotton socks; For their high ability to absorb sweat and protect against the occurrence of fungi 4- Considering the selection of age-appropriate shoes that maintain the health of the feet and avoid wearing high-heeled shoes; Because it negatively affects the health of the spine. 65 Fifth: the ears hygiene: The child depends greatly on the sense of hearing, so he receives information, and this sense directly affects his academic achievement. The ear has many functions, the most important of which is hearing and maintaining balance, in addition to its clear impact on pronunciation. The cleanliness and health of the ears must be maintained by following the following: 1- Washing the outer part of the ears daily to keep them clean 2- Dry the ears well after bathing to protect them from infections and diseases, and it is preferable to dry them using a towel. 3- Not to use the personal items of others to dry the ears. 4- Not to put foreign and sharp objects inside the ears to avoid the occurrence of wounds, especially the tympanic membrane, which affects the child’s ability to hear 5- Not to put small things in the ears, such as cotton, because they may enter the inner ear and cause infections and problems in the ears. Sixth: eyes hygiene: Sight is one of God’s blessings upon us, so it is necessary to maintain the cleanliness of the eyes to prevent them from diseases, especially since some eye infections may affect the strength of vision and the ability of a person to do his work. 1- Using the handkerchiefs and towels for everyone, with the necessity not to use the personal items of others, including pillows and bedding. 2- Combating disease-carrying insects such as flies, as they play an important role in transmitting infection from infected to non-infected people 3- Be careful to protect the eyes from entering any foreign body that may harm them and not rub them when dust enters, or when the hands are not clean because dirty hands lead to infections in the eyes and transmission of infection to the nose, ears, and mouth. 66 Seventh: the nose hygiene The nose filters the inhaled air through the capillaries in it and moisturizes it by the mucous glands. It also has a prominent role in the smelling process due to the presence of olfactory cells in its roof, which help us distinguish between different smells. The result of this function is the gathering of germs in large quantities with many types at the entrance to the nose and on its walls, and thus the nose becomes an entrance for germs that distributes them into the respiratory system, and even to the outside air in the movement of exhalation, so cleansing the nose of germs is an effective and sure way to protect the human being The nose is also very important in giving the outer shape of the face and its features, and to maintain the cleanliness of the nose, the following things must be followed: 1- Wash your nose daily with water and not inhale mucus. 2- Not to put the fingers of the hand in the nose, as this damages the membrane that lines the nose and leads to bleeding, in addition to being an undesirable habit. 3- Attention to the fact that the nasal passage needs to be always passable and open not blocked, especially in children 4- Training children to clean the nose using clean tissues 5- Not to put foreign and sharp objects inside the nostril to avoid wounds and obstruction of the airway. Eighth: dental hygiene Baby teeth are important for eating/smiling/talking / saving a place for permanent teeth Dental hygiene tips: ▪ Use a soft brush at least twice daily ▪ Replace the toothbrush every three months or after an injury to the mouth ▪ Use your brush ▪ Clean the teeth from the inside and outside tooth by tooth, and you can use a toothpick or silk floss gently to remove food residues 67 Sleep hygiene: The American Society of Sleep Medicine recommends that the child get this number of hours during sleep to support growth and development and follow healthy habits such as early sleep - regular sleep - not using visual devices before bedtime - following the rules of personal hygiene before sleeping. Age Number of sleeping hours Infants 14-15 hours 2-5 years 11-13 hours 6-12 years 10-11 hours Teenagers 9-10 hours How to support the personal hygiene of the child? Use different teaching aids / Use reminder aids / Set time / Make it fun / Be a role model 68 Diseases caused by poor personal and environmental hygiene: food poisoning diarrhea Bacterial infection pneumonia trachoma hepatitis A Viral infection diarrhea common cold and influenza scabies lice Parasitic infection amoebasis and giardiasis worms Infection: Infectious diseases arise when contaminated foreign bodies enter the human body. These foreign bodies are bacteria, viruses, fungi, or parasites. These objects are transmitted through infection from another person, animals, or contaminated food, or from exposure to any of the environmental factors that are contaminated with any of these objects. The infection may cause mild symptoms, and therefore it does not require treatment more than receiving home treatment. On the other hand, there are serious cases that may cause death. Infection cycle: The microbe (pathogen): The one that causes disease (bacteria / viruses / fungi / parasites) Source of infection: It is the place where the cause of infection lives and maybe a person, animal, soil, food, or water. Portal of exit: It is how the pathogen is released from the body that carries the disease to the outside. This may be done through the mouth when sneezing or coughing, or through blood from an open wound, the eyes, the genitals, and the anus, or when helping a sick person in the toilet. (Mouth, urine, stool, sweat, blood) 69 Method of distribution: the method of transmission of the microbe from the source of infection to humans (airborne/direct and indirect contact / by vectors such as insects/injection and blood / vertical transmission from mother to fetus / through sexual contact) Examples: By coughing By using other people's tools Through water and sewage directly or indirectly by insects portal of entry: It is how the pathogen enters the healthy human body, like the way the pathogen exits, and it may be through the mouth, nose, eyes, or open wounds. At-risk group: children / the elderly / those with chronic diseases/immunodeficiency and oncology patients /mothers during pregnancy, childbirth, and lactation Incubation period: The time between entry of a microbe and the onset of symptoms Infectious period: the period during which the patient transmits the infection to others 70 Ways to prevent infection: Daily practices of personal and environmental hygiene Vaccination isolation of the infected patients Preventive doses of antibiotics (such as in cases of meningitis and tuberculosis) Examples of common infectious diseases: Disease Microbe Symptoms Prevention measles virus fever, common cold-like vaccination, good Diseases transmitted through the respiratory system symptoms, rash, nutrition, isolation. pneumonia, eye infection, German viral fever/rash/fetal vaccination/isolatio measles abnormalities n/preventing the presence of pregnant women with infected people Mumps Viral Swollen salivary vaccination, glands/fever/difficulty personal hygiene, swallowing isolation Whooping Bacterial rhinorrhea / severe cough / vaccination/person cough fever al hygiene/isolation Complications: pneumonia/encephalitis Tuberculo bacterial fever, cough, bloody cough, vaccination, sis weight loss, personal hygiene, isolation, good nutrition. Scarlet bacterial fever/tonsillitis/rash personal fever hygiene/isolation Complications: nephritis / and preventing rheumatic fever, contact with patients 71  Disease Microbe Symptoms Prevention digestive system Gastroe viral / fever, diarrhea, personal, Diseases transmitted through the nteritis bacterial vomiting, colic, environmental, and food hygiene. Typhoid bacterial fever/constipation vaccination/person /colic al hygiene/ isolation Hepatitis virus fever, yellowing of isolation of A the eyes or skin patients, personal hygiene, Complications: Vaccination cirrhosis chickenp viral fever/rash filled isolation / personal through the skin transmitted Diseases ox with water and hygiene / crusts vaccination Impetigo bacterial vesicles contain Personal hygiene / pus on the face healthy nutrition and body 72 Schedule of compulsory vaccinations in the Arab Republic of Egypt: time of vaccination type site first 24 hrs after birth hepatitis B intramuscular injection (IM) (right thigh) at birth polio (OPV) (zero dose) oral drops tuberculosis (TB) intradermal injection 2 months polio (OPV- IPV) oral drops/ IM (left thigh) pentavalent vaccine IM (right thigh) 4 months polio (OPV- IPV) oral drops/ IM (left thigh) pentavalent vaccine IM (right thigh) 6 months polio (OPV- IPV) oral drops/ IM (left thigh) pentavalent vaccine IM (right thigh) 9 months polio (OPV) oral drops 12 months polio (OPV) oral drops MMR subcutaneous injection (right arm) booster dose at 18 months polio (OPV) oral drops DPT IM (left thigh) MMR subcutaneous (right arm) The pentavalent vaccination (diphtheria / whooping cough (pertussis) / tetanus / hepatitis B / bacterial influenza) MMR (Measles/Mumps/Rubella) DPT (diphtheria / whooping cough (pertussis) / tetanus) Additional vaccinations: Rotavirus/pneumonia/chickenpox/hepatitis A/influenza 73  Chapter IV Early intervention  Early intervention Early intervention is a system of services that helps babies and toddlers with developmental delays or disabilities. Early intervention focuses on helping eligible babies and toddlers learn the basic and brand-new skills that typically develop during the first three years of life, such as Physical (reaching, rolling, crawling and walking.) Cognitive (thinking, learning, solving problems.) Communication (talking, listening, understanding.) Social /Emotional (playing, feeling secure and happy.) Self help (eating, dressing.) Early intervention can take different forms, from home visiting programs to support vulnerable parents, to school-based programs to improve children's social and emotional skills, to mentoring schemes for young people who are vulnerable to involvement in crime. Importance of Early intervention Early intervention improves and enhances the development of a child with developmental delays, special needs or other concerns Early intervention provides assistance and support to empower families of children with developmental delay. Early intervention lays a foundation that will improve the life of the child and offer greater opportunities. Signs of Developmental Delays in Children: Developmental delays in young children refer to when a child is not reaching expected milestones in certain areas like mental, physical, or emotional growth. Types of Developmental Delays in children are several overarching types of developmental delays in children, namely Cognitive delays in infants can affect their awareness and intellectual functioning, Motor delays can interfere with your child's ability to use small and large muscle groups, which can affect both their fine motor skills (like holding onto something small or tying their shoes) and gross motor skills (like crawling or rolling over). Language delays or speech delays can limit a child's ability to understand and identify words or concepts. 75  Social, emotional, or behavioral delays can impact a child's ability to interact with others since the child may process information and react to their environment in ways that differ from other children their age. Global developmental delay (GDD): is a delay in two or more of developmental domains. Specific developmental delay (SDD): is a delay in one developmental domain. Types of Development Delay, the Signs and Causes: Infants and young children can suffer from different types of developmental delays, such as: Language or speech delay: Most common form of development delay. It refers to having difficulty in communicating verbally or in expressing and receiving information. Signs to watch for in a baby: Does not respond or babble to loud noises by 4 months Does not imitate sounds by 4 months or respond to sounds at all by 6 months Does not utter a single word by age 1 Cannot speak more than 10 words at the age of 2 Causes: A disability in learning Situation like child abuse or neglect Hearing loss in children due to infection or a result of certain medications, trauma or genetic disorders Motor skills or movement – In this, the child’s ability to walk or crawl is affected. Signs to watch for in a baby: Difficulty in reaching out or grasping objects by 4 months old The child does not roll over in any direction by 6 months Help needed in sitting up by 6 months Need support in crawling or standing by age 1 Inability to walk or push a toy by 18 months 76 Causes: Prematurely born children with improper muscle development Impairments in muscle coordination Myopathy, a disease of the muscles Problems with vision Spina bifida, a genetic condition causing partial or total paralysis of the lower part of the body Cognitive –It refers to problems with thinking and sometimes as intellectual disability as well. Signs to watch for in a baby: Inability to wave, point objects or use gestures by age 1 Difficulty in following simple instructions, imitating actions or words or using objects like spoon or hairbrush by age 2 Causes: Due to genetic defects Medical problems before birth Harmful exposure to toxin in the environment Neglect during infancy or childhood Range of different learning disabilities Down syndrome and other genetic disorders Autism spectrum disorder Vision – Vision delay means blurriness in baby’s eyes within his or her first 6 months. Signs to watch for in a baby: o No notice of hand movements by 2 months o Baby’s eyes do not follow moving objects by 3 months o Signs of constant tearing or eye drainage by 6 months o Does not follow near or far objects with both eyes by 6 months 77 Causes: Poor vision in one eye Infantile cataract – clouding of the eye’s lens Eye disease that affects infants such as retinopathy of prematurity A condition called strabismus or cross eyes Social or Emotional delay – this form of delay causes problems with the child’s ability to interact with adults or even other children. Signs to watch for in a baby: Baby is anxious all the time Shows anger quickly or seems irritated Shows discomfort in new situations Cries out quickly in difficult situations Is lethargic to try out new things Causes: Neglect from parents Ineffective parenting or attachment problems Cognitive delays Not known cause Activity: Normal or abnormal at 2 months 78  Early intervention …… who? Doctors in the primary health care Workers in child and mother care centers and rehabilitation centers Nurses Workers in vaccination campaigns for children Teachers and social workers Trained parents Early intervention …… where? Antenatal Postpartum care care and neonatal intensive care Home Pediatri School and c clinics nurseries What is Services of early intervention? This term used to describe the services and supports that are available to babies and young children with developmental delays and disabilities and their families. May include speech therapy, physical therapy, and other types of services based on the needs of the child and family. Assistive technology services and devices :Equipment and services that are used to improve or maintain a child's abilities to participate in activities such as playing, communicating, eating or moving. Hearing: identification and provision of services for children with hearing loss and prevention of hearing loss. Nutrition services: services that help meet the nutritional needs of children and that include identifying feeding skills, feeding problems, eating habits and food preferences. Occupational therapy: services related to self-help skills, adaptive behavior, play, sensory-motor, and postural development. Nursing services: assessment of a child's health status for the purpose of providing nursing care to prevent health problems, restore and improve performance, and promote optimal health and growth. This may include administering medications, treatments, and other procedures as prescribed by a licensed physician. Family Training: Services provided by qualified personnel to assist the family in understanding the special needs of the child and promoting the child's development Medical services:only for diagnostic or evaluation purposes. Physiotherapy services:that prevent or reduce movement difficulties and related functional problems Speech and language, orthotics services for children with delays in communication skills or motor skills such as weak muscles around the mouth or swallowing Psychological services:administering and interpreting psychological tests and information about a child's behavior and family conditions related to learning, mental health and development as well as organizing services including counseling and consultation, parent training and education programmes 80 Impairment, Disability, and Handicap: What’s the Difference? Impairment is defined as “any loss or abnormality of psychological, physiological or anatomical structure or function.” Disability, on the other hand, means “any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.” Lastly, handicap is defined as “a disadvantage for a given individual that limits or prevents the fulfillment of a role that is normal.” For example: Physical impairment pertains to a loss of an anatomical structure; let’s say the person lost a leg due to an accident. He can wear prosthetics as a replacement of the lost leg. Physical disability now refers to the inability to walk. To be able to navigate the surroundings, the person can use a wheelchair. Physical handicap now means that this person faces disadvantages that prevent him or her to perform a normal role in life, such as not being able to climb stairs anymore. Or run a marathon. Or be a basketball player. Here is where the environment plays a part. By providing wheelchair access or lift for the person with physical disability, he or she will have no problem going up to the next floors of a building. By providing multi-sport events for athletes with physical disabilities, such as Paralympics, the person will still able to participate in sports. 81 Another example: Dyslexia is an example of learning impairment, a reading impairment in particular. Let’s say the student has an above-average intelligence as well as good vision and hearing. Therefore, the impairment is the brain’s inability to decode words to be able to read. The brain cannot correctly associate the sounds with the letter symbols. The inability to read is now the student’s learning disability. It can be improved by employing specific intervention programs such as multi- sensory instruction in teaching reading. The person may experience various learning handicaps in school, and he or she may fail in class. For example, the student may not be able to complete the reading requirements in class. However, if certain adjustments are provided for the learner, such as taping lectures and listening to books on audiotapes, then he or she may fare well, similar to his or her peers. This will decrease the student’s handicap and will not interfere with his or her progress in school. There are many types of disabilities like: mobility_ physical cognitive vision hearing spinal cord head injuries _brain disability Hidden/ invisible disability Disabilities can be related to: the pregnancy period disorders of chromosomes like (Down syndrome) disorders of genes like (Duchenne muscular dystrophy) To the result of the exposure during pregnancy to infections like (rubella) : the baby may die may get deformed may have congenital defects of heart or other organs the baby can also be affected if the mother drink (alcohol or cigarettes) 82 disabilities can be associated with developmental condition that become apparent during childhood like autism spectrum disorders, attention deficit hyperactivity disorders (ADHD) an injury like traumatic brain injury, spinal cords injury longstanding condition like diabetes which can cause a disability such as vision loss, nerve damage or limb loss. progressive ((muscular dystrophy)) static like( limb loss) Intermittent like(multiple sclerosis) 83  Early intervention services usually continue until the age of three. But this does not mean that the program will stop abruptly when the child turns three, early intervention services may continue beyond his third birthday if nece