Wong's Nursing Care of Infants and Children 11th Edition PDF

Wong's Nursing Care of Infants and Children 11TH EDITION MARILYN J. HOCKENBERRY, PhD, RN, PPCNP-BC, FAAN Bessie Baker Professor of Nursing and Professor of Pediatrics Associate Dean of Research Affairs, School of Nursing Chair, Duke Institutional Review Board Duke University Durham, North Carolina DAVID WILSON, MS, RNC-NIC (deceased) Staff Children's Hospital at Saint Francis 2 Tulsa, Oklahoma CHERYL C. RODGERS, PhD, RN, CPNP, CPON (deceased) Associate Professor Chair, Duke Institutional Review Board Duke University School of Nursing Durham, North Carolina 3 Table of Contents Instructions for online access Cover image Title Page Copyright Dedication Contributors Reviewers Preface Organization of the Book Unifying Principles Special Features 4 Acknowledgments Section I Children, Their Families, and the Nurse 1 Perspectives of Pediatric Nursing Health Care for Children The Art of Pediatric Nursing Clinical Reasoning and the Process of Providing Nursing Care to Children and Families NCLEX Review Questions Correct Answers References 2 Social, Cultural, Religious, and Family Influences on Child Health Promotion General Concepts Family Structure and Function Family Roles and Relationships Parenting Special Parenting Situations Sociocultural Influences on Children and Families Influences in the Surrounding Environment Broader Influences on Child Health NCLEX Review Questions Correct Answers 5 References 3 Hereditary Influences on Health Promotion of the Child and Family Genetic/Genomic Nursing Competencies Disorders of the Intrauterine Environment Inborn Errors of Metabolism Impact of Hereditary Disorders on the Family NCLEX Review Questions Correct Answers References Section II Childhood and Family Assessment 4 Communication, Physical, and Developmental Assessment of the Child and Family Guidelines for Communication and Interviewing Resources for Telephone Triage Protocols Communicating With Families History Taking Nutritional Assessment General Approaches Toward Examining the Child Physical Examination References 6 References NCLEX Review Questions Correct Answers References 5 Pain Assessment and Management in Children What Is Pain and How Does It Occur? What Does Pain Do Besides Hurt? Common Acute Pain Conditions in Children Common Chronic Pain Conditions in Children Common Mixed-Pain Conditions in Children Measuring Pain in Children Chronic and Recurrent Pain Assessment Prevention and Treatment of Pain in Children NCLEX Review Questions Correct Answers References 6 Childhood Communicable and Infectious Diseases Infection Control Communicable Diseases Intestinal Parasitic Diseases NCLEX Review Questions 7 Correct Answers References Section III Family-Centered Care of the Newborn 7 Health Promotion of the Newborn and Family Adjustment to Extrauterine Life Nursing Care of the Newborn and Family NCLEX Review Questions Correct Answers References 8 Health Problems of the Newborn Birth Injuries Cranial Deformities Dermatologic Problems in the Newborn Problems Related to Physiologic Factors Problems Caused by Perinatal Environmental Factors NCLEX Review Questions Correct Answers References 9 The High-Risk Newborn and Family General Management of High-Risk Newborns 8 Nursing Care of High-Risk Newborns High-Risk Conditions Related to Dysmaturity High Risk Related to Disturbed Respiratory Function High Risk Related to Infectious Processes High Risk Related to Cardiovascular and Hematologic Complications High Risk Related to Neurologic Disturbance High Risk Related to Maternal Conditions NCLEX Review Questions Correct Answers References Section IV Family-Centered Care of the Infant 10 Health Promotion of the Infant and Family Promoting Optimum Growth and Development Promoting Optimum Health During Infancy NCLEX Review Questions Correct Answers References 11 Health Problems of the Infant Nutritional Imbalances Health Problems Related to Nutrition 9 Special Health Problems NCLEX Review Questions Correct Answers References Section V Family-Centered Care of the Toddler and Preschooler 12 Health Promotion of the Toddler and Family Promoting Optimum Growth and Development Temperament Coping With Concerns Related to Normal Growth and Development Promoting Optimum Health During Toddlerhood NCLEX Review Questions Correct Answers References 13 Health Promotion of the Preschooler and Family Promoting Optimum Growth and Development Promoting Optimum Health During the Preschool Years NCLEX Review Questions Correct Answers References 10 14 Health Problems of Early Childhood Sleep Problems Ingestion of Injurious Agents Child Maltreatment NCLEX Review Questions Correct Answers References Section VI Family-Centered Care of the School- Age Child 15 Health Promotion of the School-Age Child and Family Promoting Optimum Growth and Development Coping With Concerns Related to Normal Growth and Development Promoting Optimum Health During the School Years NCLEX Review Questions Correct Answers References 16 Health Problems of the School-Age Child Obesity: Complications, Treatment, and Prevention Dental Disorders Disorders of Continence 11 NCLEX Review Questions Correct Answers References Section VII Family-Centered Care of the Adolescent 17 Health Promotion of the Adolescent and Family Promoting Optimum Growth and Development Promoting Optimum Health During Adolescence NCLEX Review Questions Correct Answers References 18 Health Problems of the Adolescent Health Conditions of the Male Reproductive System Health Conditions of the Female Reproductive System Health Conditions Related to Reproduction Health Conditions With a Behavioral Component Substance Abuse Self-Harm Suicide NCLEX Review Questions Correct Answers 12 References Section VIII Family-Centered Care of the Child With Special Needs 19 Impact of Chronic Illness, Disability, or End-of-Life Care for the Child and Family Perspectives on the Care of Children and Families Living With or Dying From Chronic or Complex Diseases The Family of the Child With a Chronic or Complex Condition The Child With a Chronic or Complex Condition Nursing Care of the Family and Child With a Chronic or Complex Condition Palliative Care in Childhood Terminal Illness Nursing Care of the Child and Family at the End of Life Special Decisions at the Time of Dying and Death Care of the Grieving Family The Nurse and the Child With Life-Threatening Illness NCLEX Review Questions Correct Answers References 20 Impact of Cognitive or Sensory Impairment on the Child and Family Cognitive Impairment Nursing Care of Children With Impaired Cognitive Function 13 Sensory Impairment Communication Impairment References NCLEX Review Questions Correct Answers References Section IX The Child Who Is Hospitalized 21 Family-Centered Care of the Child During Illness and Hospitalization Stressors of Hospitalization and Children's Reactions Stressors and Reactions of the Family of the Child Who Is Hospitalized Nursing Care of the Child Who Is Hospitalized Nursing Care of the Family Care of the Child and Family in Special Hospital Situations NCLEX Review Questions Correct Answers References 22 Pediatric Nursing Interventions and Skills General Concepts Related to Pediatric Procedures Skin Care and General Hygiene 14 Safety Positioning for Procedures Collection of Specimens References Administration of Medication References Maintaining Fluid Balance Alternative Feeding Techniques References Procedures Related to Elimination NCLEX Review Questions Correct Answers References Section X Childhood Nutrition and Elimination Problems 23 The Child With Fluid and Electrolyte Imbalance Distribution of Body Fluids Disturbances of Fluid and Electrolyte Balance Nursing Responsibilities in Fluid and Electrolyte Disturbances Burns NCLEX Review Questions 15 Correct Answers References 24 The Child With Renal Dysfunction Renal Structure and Function Genitourinary Tract Disorders References Glomerular Disease Renal Tubular Disorders Miscellaneous Renal Disorders Renal Replacement Therapy Defects of the Genitourinary Tract Disorders of Sex Development NCLEX Review Questions Correct Answers References 25 The Child With Gastrointestinal Dysfunction Gastrointestinal Structure and Function Gastrointestinal Disorders References Ingestion of Foreign Substances Disorders of Motility 16 Inflammatory Conditions Obstructive Disorders Malabsorption Syndromes Hepatic Disorders Structural Defects Hernias NCLEX Review Questions Correct Answers References Section XI Childhood Oxygenation Problems 26 The Child With Respiratory Dysfunction Respiratory Tract Structure Assessment of Respiratory Function Defenses of the Respiratory Tract General Aspects of Respiratory Tract Infections Upper Respiratory Tract Infections Croup Syndromes Infections of the Lower Airways Other Infections of the Respiratory Tract Respiratory Disturbance Caused by Noninfectious Irritants Structural Defects 17 Long-Term Respiratory Dysfunction Respiratory Emergency NCLEX Review Questions Correct Answers References Section XII Childhood Blood Production and Circulation Problems 27 The Child With Cardiovascular Dysfunction Cardiac Structure and Function Acquired Cardiovascular Disorders NCLEX Review Questions Correct Answers References 28 The Child With Hematologic or Immunologic Dysfunction The Hematologic System and Its Function Red Blood Cell Disorders Anemia Caused by Nutritional Deficiencies Anemias Caused by Increased Destruction of Red Blood Cells References Anemias Caused by Impaired or Decreased Production of Red Blood Cells 18 Other Hematologic Disorders Immunologic Deficiency Disorders NCLEX Review Questions Correct Answers References Section XIII Childhood Regulatory Problems 29 The Child With Cancer Cancer in Children Nursing Care Management Cancers of Blood and Lymph Systems Nervous System Tumors Bone Tumors Other Solid Tumors The Childhood Cancer Survivor NCLEX Review Questions Correct Answers References 30 The Child With Cerebral Dysfunction Cerebral Structure and Function Evaluation of Neurologic Status The Child With Cerebral Compromise 19 Intracranial Infections References Seizures and Epilepsy References Headache The Child With Cerebral Malformation NCLEX Review Questions Correct Answers References 31 The Child With Endocrine Dysfunction The Endocrine System Disorders of Pituitary Function Disorders of Thyroid Function Disorders of Parathyroid Function Disorders of Adrenal Function Disorders of Pancreatic Hormone Secretion NCLEX Review Questions Correct Answers References Section XIV Childhood Physical Mobility Problems 20 32 The Child With Integumentary Dysfunction Integumentary Dysfunction Infections of the Skin Skin Disorders Related to Chemical or Physical Contacts Skin Disorders Related to Animal Contacts Rickettsial Diseases Miscellaneous Skin Disorders Skin Disorders Associated With Specific Age-Groups Cold Injury NCLEX Review Questions Correct Answers References 33 The Child With Musculoskeletal or Articular Dysfunction The Child and Trauma The Immobilized Child The Child With a Fracture Injuries and Health Problems Related to Sports Participation Musculoskeletal Dysfunction Orthopedic Infections Skeletal and Articular Dysfunction NCLEX Review Questions 21 Correct Answers References 34 The Child With Neuromuscular or Muscular Dysfunction Neuromuscular Dysfunction Defects of Neural Tube Closure Muscular Dysfunction NCLEX Review Questions Correct Answers References Index Blood Pressure Levels 22 Copyright 3251 Riverport Lane St. Louis, Missouri 63043 WONG'S NURSING CARE OF INFANTS AND CHILDREN, ELEVENTH EDITION ISBN: 978-0-323-54939-4 Copyright © 2019, Elsevier Inc. All rights reserved. Previous editions copyrighted 2015, 2011, 2007, 2003, 1999, 1995, 1991, 1987, 1983, 1979 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any 23 information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Control Number: 2018941061 Senior Content Strategist: Sandra Clark Senior Content Development Specialist: Heather Bays Publishing Services Manager: Julie Eddy Senior Project Manager: Tracey Schriefer Design Direction: Renee Duenow Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1 24 Dedication We dedicate the eleventh edition of this book to David Wilson, who passed away on March 7, 2015, after a long battle with cancer. David had been coauthor of the Wong nursing textbooks for over 15 years. He was known as an expert clinical nurse and nurse educator. His last clinical position was at St. Francis Health Services in Tulsa, Oklahoma, where he worked in the Children's Day Hospital as the coordinator for Pediatric Advanced Life Support (PALS). Students and faculty have recognized David's contributions to the Wong textbooks for many years. He was known as an outstanding educator and supporter of nursing students; his attention to clinical 25 excellence was evident in all his work. Those who contributed to the books and had the opportunity to work with David realize the important role he played as a leader in nursing education for students and faculty. His clinical expertise provided a critical foundation for ensuring that relevant and evidence-based content was used in all the Wong textbooks. David led by example in exemplifying excellence in clinical nursing practice. Those who knew David well will miss his humor, loyalty to friends and colleagues, and his never-ending support. He is missed greatly by those who worked closely with him on the Wong textbook over the years. Most important, we miss his friendship; he was always there to support and to encourage. We have lost an amazing nurse who worked effortlessly over the years to improve the care of children and families in need. David will not be forgotten. It is with great sadness that we announce the passing of Dr. Cheryl Rodgers on July 7th, 2018, following a tragic accident. Cheryl was an exemplary nurse practitioner, educator, and leader in the field of pediatric nursing. 26 Cheryl was an Associate Professor in the Duke University School of Nursing, and she held national leadership positions in the Children's Oncology Group Nursing Discipline and the Association of Pediatric Hematology Nurses. She served on the Journal of Pediatric Oncology Nursing Editorial Board, led several funded research studies, authored numerous impactful publications, and had just been selected for induction as a Fellow in the American Academy of Nursing, the profession's highest honor. Her devotion to pediatric nursing education served her well as a Wong textbook editor and she will be greatly missed. Most importantly, Cheryl was an outstanding role model and treasured mentor to so many pediatric nurses; her loss will be felt broadly and deeply throughout the profession. 27 Contributors Caroline E. Anderson RN, MSN, CPHON Clinical Practice and Advanced Education Specialist Cook Children's Medical Center Fort Worth, Texas Annette L. Baker RN, BSN, MSN, CPNP Pediatric Nurse Practitioner Department of Cardiology Boston Children's Hospital Boston, Massachusetts Rose Ann Urdiales Baker, PhD, PMHCNS, RN Associate Instructor School of Nursing College of Health Professions University of Akron Akron, Ohio Raymond C. Barfield MD, PhD Professor of Pediatrics and Christian Philosophy; Director, Medical Humanities Pediatrics, and Trent Center for Bioethics, Humanities, and History of Medicine Duke University Durham, North Carolina Amy Barry MSN, RN, PNP-BC Pediatric Nurse Practitioner Children's Healthcare of Atlanta 28 Atlanta, Georgia Heather Bastardi RN, cPNP, CCTC Pediatric Nurse Practitioner Advanced Cardiac Therapies Boston Children's Hospital Boston, Massachusetts Debra Brandon PhD, RN, CNS, FAAN Associate Professor School of Nursing Duke University Associate Professor Department of Pediatrics, School of Medicine Duke University Neonatal CNS Duke Intensive Care Nursery Durham, North Carolina Rosalind Bryant PhD, RN-CS, PNP Clinical Instructor Baylor College of Medicine Houston, Texas Cynthia J. Camille MSN, RN, CPNP, FNP-BC Pediatric Nurse Practitioner Pediatric Urology Duke University Health System Durham, North Carolina Brigit M. Carter PhD, RN, CCRN Director Accelerated BSN Program Duke University School of Nursing Durham, North Carolina Lisa M. Cleveland PhD, RN, PNP-BC, IBCLC, NTMNC Assistant Professor School of Nursing UT Health San Antonio 29 San Antonio, Texas Patricia Conlon MS, APRN, CNS, CNP Pediatric Clinical Nurse Specialist Assistant Professor of Nursing Mayo Clinic Children's Center Rochester, Minnesota Erin Connelly APRN, CPNP, CPON Developmental Therapeutics Nurse Practitioner Department of Hematology Children's Healthcare of Atlanta Clinical Manager of Advance Practice Department of Oncology Aflac Cancer and Blood Disorders Center Atlanta, Georgia Anne Derouin DNP, APRN, CPNP, FAANP Associate Professor, Faculty Lead, MSN/PNP-PC and Pediatric Behavioral Mental Health Specialty School of Nursing Duke University Durham, North Carolina Sharron L. Docherty PhD, PNP-BC, FAAN Associate Professor Department of Pediatrics Duke University Durham, North Carolina Angela Drummond MS, APRN, CPNP Pediatric Nurse Practitioner–Orthopedics Gillette Children's Specialty Healthcare St. Paul, Minnesota Elizabeth A. Duffy DNP, RN, CPNP Clinical Assistant Professor Health Behavior and Biological Sciences The University of Michigan School of Nursing Ann Arbor, Michigan 30 Kimberley Fisher PhD, FNP-BC Research Director Neonatal Perinatal Research Unit Division of Neonatology Duke University Durham, North Carolina Jan M. Foote DNP, CPNP, ARNP, FAANP Pediatric Nurse Practitioner Blank Children's Hospital Des Moines, Iowa Adjunct Clinical Associate Professor University of Iowa College of Nursing Iowa City, Iowa Quinn Franklin MS, CCLS Assistant Director Psychosocial Division Cancer and Hematology Centers Texas Children's Hospital Houston, Texas Ruth Anne Herring MSN, RN, CPNP-AC/PC, CPHON Pediatric Nurse Practitioner Center for Cancer and Blood Disorders Children's Health Dallas, Texas Mystii Kidd MSN, RN, CPNP Pediatric Nurse Practitioner TLC Pediatrics, PA Allen, Texas Teri A. Huddleston Lavenbarg MSN, APRN, PPCNP-BC, FNP- BC, CDE Nurse Practitioner Medical Center University of Kansas Kansas City, Kansas 31 Shirley D. Martin PhD, RN, CPN Outpatient Surgery Cook Children's Medical Center Fort Worth, Texas Maggie Maxtin RN, BSN, CPN Hematology/Oncology RN Cook Children's Medical Center Fort Worth, Texas Patricia Barry McElfresh MN, RN, PNP Clinical Program Manager - Advanced Practice Providers Hematology Oncology-Bone Marrow Failure Aflac Cancer & Blood Disorders Center Atlanta, Georgia Tara Merck MSN, APRN, CPNP Director of Advanced Practice Providers Children's Specialty Group Medical College of Wisconsin Milwaukee, Wisconsin Mary A. Mondozzi MSN, BSN, WCC Burn Center Education/Outreach Coordinator The Paul and Carol David Foundation Burn Institute Akron Children's Hospital Akron, Ohio Rebecca A. Monroe MSN, RN, CPNP Pediatric Nurse Practitioner Collin County Pediatrics Frisco, Texas Kim Mooney-Doyle PhD, CPNP-AC, RN Assistant Professor School of Nursing University of Maryland Baltimore, Maryland Patricia O’Brien CPNP-AC 32 Nurse Practitioner Cardiology Boston Children's Hospital Boston, Massachusetts Sue Park APN, CPNP-PC Pediatric Nurse Practitioner Pediatric Anesthesia Ann and Robert H. Lurie Children's Hospital of Chicago Chicago, Illinois Katherine Soss Prihoda DNP, RN, PPCNP-BC Assistant Professor School of Nursing Rutgers University, Camden Camden, New Jersey Cynthia A. Prows MSN, APRN, FAAN Clinical Nurse Specialist Human Genetics and Patient Services Cincinnati Children's Hospital Medical Center Cincinnati, Ohio Patricia A. Ring MSN, RN, CPNP Pediatric Nephrology Children's Hospital of Wisconsin Milwaukee, Wisconsin Kathleen S. Ruccione PhD, RN, MPH, CPON, FAAN Associate Professor and Chair Department of Doctoral Programs Azusa Pacific University Azusa, California Margaret L. Schroeder MSN, RN, PPCNP-BC Pediatric Nurse Practitioner Cardiovascular Surgery Boston Children's Hospital Boston, Massachusetts 33 Maureen Sheehan CPNP Child Neurology, Epilepsy, and Ketogenic Diet Nurse Practitioner Child Neurology and Advanced Practice Stanford Children's Health Palo Alto, California Katherine Smalling RN, BSN, CPON Nurse Case Manger Children's Medical Center Dallas Center for Cancer and Blood Disorders Dallas, Texas Anne Feierabend Stanton APRN, PCNS, BC Pediatric Clinical Nurse Specialist University of Kansas Medical Center Kansas City, Kansas Alexandra Kathleen Superdock MD Pediatric Resident University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Barbara J. Wheeler RN, MN, IBCLC Neonatal Clinical Nurse Specialist St. Boniface General Hospital Winnipeg, Canada Kristina D. Wilson PhD, CCC-SLP Senior Speech Pathologist and Clinical Research Division of Speech, Language, and Learning Texas Children's Hospital Houston, Texas Case Studies and Review Questions Stephanie Cope Evans PhD, APRN, CPNP-PC Assistant Professor of Nursing Harris College of Nursing & Health Sciences Texas Christian University Fort Worth, Texas Key Points 34 Joanna Cain BSN, BA, RN Auctorial Pursuits, Inc. President and Founder Austin, Texas PowerPoint Lecture Slides Daryle Wane PhD, ARNP, FNP-BC BSN Program Director—Professor of Nursing Department of Nursing and Health Programs Pasco-Hernando State College New Port Richey, Florida TEACH for Nursing Jenni Hermes Freelance St. Louis, Missouri Test Bank Sherry Conder BSHA, RN Adult Career Development Tulsa Technology Center Tulsa, Oklahoma 35 Reviewers Sharon Anderson DNP, RN, APN, NNP-BC, APNG Assistant Professor Entry into Baccalaureate Practice Rutgers, The State University of New Jersey School of Nursing Newark, New Jersey Kristen Bagby RN, MSN, CNL Staff Nurse Newborn Intensive Care Unit Saint Louis Children's Hospital Saint Louis, Missouri William T. Campbell EdD, MSN, RN Associate Professor Nursing Salisbury University Salisbury, Maryland Rebecca E. Chatham MSN, RN, CPN Assistant Professor of Nursing Jeannette C. Rudy School of Nursing Cumberland University Lebanon, Tennessee Teresa M. Conte PhD, CPNP Associate Professor Nursing University of Scranton 36 Scranton, Pennsylvania Claire M. Creamer PhD, RN, CPNP-PC Assistant Professor of Nursing Nursing Rhode Island College Providence, Rhode Island Jo Ann Cummings PhD, RN, APN, PPCNP Assistant Professor Nursing Georgian Court University Lakewood, New Jersey Raquel Burciaga Engolio RN, MSN, CPN Assistant Professor Nursing University of Holy Cross New Orleans, Louisiana Teresa Howell DNP, RN, CNE Professor of Nursing Department of Nursing Morehead State University Morehead, Kentucky Christine B. Kavanagh RD, MS, PNP-BC Instructor Nursing Programs School of Health Sciences The Pennsylvania College of Technology Williamsport, Pennsylvania Renee C.B. Manworren PhD, RN-BC, APRN, PCNS-BC, AP-PMN, FAAN Posy and Fred Love Chair in Nursing Research Director of Nursing Research and Professional Practice Ann and Robert H. Lurie Children's Hospital of Chicago Associate Professor of Pediatrics, Northwestern University's Feinberg School of Medicine 37 Chicago, Illinois Elizabeth K. Rende DNP, RN, CPNP-PC Assistant Professor and Pediatric Nurse Practitioner Duke School of Nursing and Duke Pediatric Neurology Duke University and Duke University Medical Center Durham, North Carolina Deborah Spoerner MSN, RN, CPNP, DNPc Clinical Assistant Professor School of Nursing Purdue University West Lafayette, Indiana 38 Preface With this eleventh edition of Wong's Nursing Care of Infants and Children, we welcome Cheryl Rodgers, who joins Marilyn Hockenberry as coeditor. We would like to take a moment to reflect on the legacy of this textbook. The first edition, published in 1979, was the first of its kind to integrate important principles from the biologic, physical, and behavioral sciences into a pediatric nursing textbook (Whaley & Wong, 1979). With the first edition, the principles and concepts of nursing practice were conceptualized to allow both beginning students and experienced nurses an opportunity to expand and refine nursing care; this proves true with this eleventh edition. The first edition, compared with the eleventh edition, clearly reflects 21st-century changes in pediatric nursing and demonstrates how scientific evidence has had a significant impact on the specialty. In the first edition, there is no mention of the human genome project, human immunodeficiency virus, autism disorders, respiratory syncytial virus, acute respiratory distress syndrome, acute lung injury, and cystic-fibrosis–related diabetes mellitus; they had yet to be discovered or named. The first edition of this text was perhaps the first pediatric nursing text to recognize the impact of illness and hospitalization on the child and her or his family. It was also first to introduce the concept of family-centered care in an era when the focus of care was centered on the diagnosis and treatment of the disease process. Although the differences in content between the first Nursing Care of Infants and Children textbook and this eleventh edition are evident, the founding principles on which the first edition was established hold true today. This eleventh edition continues to be 39 about families with children, and it emphasizes the philosophy of family-centered care. This book has retained the theme that Donna Wong so passionately advocated: providing atraumatic care—care that minimizes the psychologic and physical stress that health promotion and illness can inflict. The first edition's preface stated, “This books truly embodies the concept of [family-centered] care.” We are proud to note that with this new edition, this foundation remains true. Features such as Family-Centered Care, Community Focus, and Atraumatic Care boxes bring these philosophies to life throughout the text. We believe strongly that children and families need consistent caregivers. Establishing therapeutic relationships with the child and family is explored as the essential foundation for providing quality nursing care. This eleventh edition has been revised to keep pace with new innovations in pediatric nursing care. We feel a unique accountability and responsibility to continue to strive to provide students with the latest information they need to become competent critical thinkers and to attain the sensitivity necessary to become caring pediatric nurses. As editors for the Wong textbooks, we have developed an expert panel of more than 60 nurses and multidisciplinary specialists who assisted in reviewing, revising, rewriting, and authoring portions of the text on areas undergoing rapid and complex change, such as immunizations, genetics, high- risk newborn care, adolescent health issues, and numerous diseases. We have carefully preserved aspects of the book that have met with such universal acceptance—its state-of-the-art evidence- based information; strong, integrated focus on the family and community; logical and user-friendly organization; and easy reading style. We have placed additional emphasis on research with concise reviews of important evidence in Research Focus boxes. With this eleventh edition we emphasize the importance of care evaluation and have added quality indicator boxes throughout the book to demonstrate how quality of care can be assessed among the pediatric population. This format allows students to review new evidence and quality indicators on important topics in a concise way. Throughout the chapters the reader will find quality patient outcomes that focus on serious health problems. Because nurses are the principal caregivers within health care institutions, quality 40 patient outcomes are used as an assessment of the ability to provide excellence in patient care. Pathophysiology review figures throughout the text provide a concise evaluation of major health care diseases in children. With an understanding of the pathophysiologic process, the nurse is better prepared to develop evidence-based nursing interventions for patient care. In addition, more than 130 figures are color enhanced to focus on the importance on visual learning. This provides the visual learner with a tangible connection to the content of the text for application to clinical practice. We have tried to meet the increasing demands of faculty and students to teach and to learn in an environment characterized by rapid change, enormous amounts of information, fewer traditional clinical facilities, and less time to teach. To help students quickly locate essential information, most of the features used in the previous edition have been retained. We continue to use Evidence- Based Practice boxes incorporating the PICOT approach and GRADE evidence quality assessment criteria. Most important, this text continues to encourage students to think critically. This text serves as a reference manual for the practicing nurse. The latest recommendations have been included from authoritative organizations such as the American Academy of Pediatrics, Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, American Pain Society, American Nurses Association, and National Association of Pediatric Nurse Associates and Practitioners. To expand the universe of available information, websites and e-mail addresses have been included for hundreds of organizations and other educational resources. Organization of the Book The same general approach to the presentation of content has been preserved from previous editions, although much content has been added, condensed, and rearranged within this framework to improve flow, minimize duplication, and emphasize health care trends, such as home and community care. This edition has been revised and refined to minimize content duplication, resulting in 34 chapters. The book continues to be divided into two broad parts. The first part of the book, sometimes called the “age and stage” 41 approach, considers infancy, childhood, and adolescence from a developmental context. It emphasizes the importance of the nurse's role in health promotion and maintenance and in considering the family as the focus of care. From a developmental perspective, the care of common health problems is presented, giving readers a sense of what normal problems can be expected in otherwise healthy children and demonstrating when during childhood these problems are most likely to occur. The second part of the book presents the more serious health problems not specific to any particular age-group but that frequently require hospitalization or major medical and nursing interventions. Unit I (Chapters 1 to 3) provides an overview of the multitude of influences on a child who is developing as a member of a family unit and maturing within a culture, community, and society. Chapter 1 includes a discussion of morbidity and mortality in infancy and childhood and examines child health care from a historical perspective. Because unintentional injury is one of the leading causes of death in children, an overview of this topic is included. The chapter presents the nursing process, with an emphasis on nursing diagnosis and outcomes and the importance of developing critical thinking skills. The critical components of evidence-based practice provide the template for exploring the latest pediatric nursing research and practice guidelines throughout the entire book. Discussion of quality patient outcomes and their importance in evaluating the quality of nursing care has been added. Chapter 2 provides the opportunity to expand the discussion of social, cultural, religious, and family influences on child development and health promotion, including socioeconomic factors, customs, and health beliefs and practices. The content clearly describes the role of the nurse, with such content as guidelines for culturally sensitive interactions and a table discussing religious beliefs that affect nursing care. Chapter 3 has been revised by a leading genetics nursing expert, who focuses on heredity as it relates to health promotion and the influence of the Human Genome Project on future treatment strategies for inherited diseases. Unit II (Chapters 4 to 6) is concerned with the principles of critical nursing assessment by keeping pace with the newest 42 evaluation strategies in nursing. Chapter 4 contains guidelines for communicating with children, adolescents, and their families; telephone triage; and a detailed description of a health assessment, including an extensive discussion of family assessment and nutritional assessment. This chapter provides a comprehensive approach to physical examination and developmental assessment, using the latest literature on temperature measurement and the latest growth charts on how to assess a child's body mass index (BMI). In this edition, an important chapter with new contributors is devoted to critical assessment and management of pain in children. Although the literature on pain assessment and management in children has grown considerably, this knowledge has not been widely applied in practice. Chapter 5 addresses this concern by presenting detailed pain assessment and management strategies, including discussion of common pain states in children. Chapter 6 is a newly developed chapter for the eleventh edition that focuses on infection control and the various infectious diseases encountered in childhood. In addition, it details hospital-acquired infections, childhood communicable diseases, and childhood immunizations. Unit III (Chapters 7 to 9) stresses the importance of the neonatal period, the time of greatest risk to a child's survival, and discusses several health concerns encountered in the vulnerable first month of life. Chapter 7 has been updated and revised to include the latest information on the benefits of breastfeeding and dietary intake of vitamin D. Atraumatic care sections have been revised to include the latest evidence-based recommendations for pain management in newborns. This chapter also discusses the impact of prebiotics and probiotics on infant nutrition and well-being. The sections on infant safety, newborn circumcision, and circumcision analgesia have all been revised and updated. Newborn screening guidelines have also been extensively updated. Chapter 8 has been revised and updated by a new contributor who is an expert in high-risk neonatal care. The latest guidelines for the management of hyperbilirubinemia in late-preterm and term newborns and for follow-up and management of hyperbilirubinemia in the breastfeeding pair are included in this edition. The chapter includes updated sections on care of the infant with cleft lip or palate and Pierre Robin sequence. Updated management protocols for 43 neonatal hypoglycemia are also included. Atraumatic care of the newborn remains an important concept in these chapters. Evidence- based practice and critical thinking exercises have been updated as well. Chapter 9, revised and updated by a new contributor, includes updated and revised sections on care of the preterm infant, including therapeutic positioning, preterm infant nutrition, revised guidelines for supplemental oxygen administration, noninvasive (gentle) mechanical ventilation, necrotizing enterocolitis, neonatal sepsis, discharge planning, retinopathy of prematurity, neonatal skin care guidelines, and neonatal/perinatal stroke. The most recent information regarding hypoxic ischemic reperfusion injury and therapeutic hypothermia are presented in this chapter. This chapter also contains information regarding maternal conditions that may adversely affect the fetus and newborn, including maternal viruses, maternal diabetes, fetal alcohol and tobacco exposure, and neonatal drug exposure. Units IV through VII (Chapters 10 to 18) present the major developmental stages in childhood, expanded to provide a broader concept of the stages and the health problems most often associated with each age-group. Special emphasis is placed on the preventive aspects of care. The health promotion chapters follow a standard approach that is used consistently for each age-group. The chapters on health problems primarily reflect typical and age-related concerns. The information on many disorders has been revised to reflect recent changes. Examples include the latest information on food sensitivity, severe acute malnutrition, colic, failure to thrive, child passenger safety, pacifier use, thumb sucking, lead poisoning, sexual abuse, attention- deficit/hyperactivity disorder, school-related violence, conduct disorders, tobacco use, contraception, teenage pregnancy, substance abuse, self-harm, and eating disorders such as anorexia nervosa and childhood obesity. This section presents the latest Dietary Reference Intake (DRI) guidelines, American Heart Association dietary guidelines for children, and U.S. Department of Agriculture dietary intake guidelines for children (MyPlate), aimed at decreasing childhood obesity and cardiovascular disease. The sections on sudden infant death syndrome (SIDS) and apparent life-threatening events (ALTEs) have been extensively updated to include the latest American Academy of Pediatrics considerations for recognized 44 SIDS protective and risk factors. A common theme in these chapters is the recognition of the impact of accidental childhood injury on childhood morbidity and mortality and efforts for prevention of such injuries. Childhood obesity information is now located in the school-age child chapter to emphasize the need for earlier assessment and intervention of this health problem. The chapters on adolescence include the latest information on the management of eating disorders, and also recommendations for preventive health screening in adolescents. Sections on male and female reproductive health conditions and sexual orientation have been revised and updated. The chapter includes updates on the latest screening guidelines for adolescent hypertension and hyperlipidemia. Unit VIII (Chapters 19 and 20) deals with children who have the same developmental needs as growing children but who, because of congenital or acquired physical, cognitive, or sensory impairment, require alternative interventions to facilitate development. Chapter 19 combines discussion of chronic illness, disability, and end-of-life care for the child and family. It reflects the latest trends in the care of families and children with chronic illness or disability, such as home care, normalizing children's lives, focusing on developmental needs, enabling and empowering families, and providing early intervention. The content in Chapter 20 on cognitive, sensory, and communication impairment includes the latest information on cognitive impairment and learning disorders. Unit IX (Chapters 21 and 22) is concerned with the impact of hospitalization on the child and the family and presents a comprehensive overview of the stressors imposed by hospitalization and nursing interventions available to prevent or eliminate these stressors. Chapter 21 discusses the care of the hospitalized child and family with consideration for increasing care in ambulatory centers. Chapter 22 explores safe implementation of procedures in children, including emphasis on the use of therapeutic holding. This chapter also includes numerous Evidence- Based Practice boxes designed to provide rationales for the interventions discussed in the chapter. Recommendations for practice are based on the evidence and are concisely presented in Evidence-Based Practice boxes throughout the chapter. 45 Units X through XIV (Chapters 23 to 34) consider serious health problems of infants and children primarily from a biologic system orientation, which has the practical organizational value of permitting health care problems and nursing considerations to relate to specific pathophysiologic disturbances. Important additions and revisions include discussion of hepatitis, all blood disorders, influenza management recommendations, acute respiratory distress syndrome/acute lung injury (ARDS/ALI), respiratory syncytial virus (RSV), tuberculosis, the latest classification for asthma, effects of tobacco exposure, seizures, chemotherapy, acquired immunodeficiency syndrome, diabetes mellitus, and burns. Examples of the updates and revisions for these units include the following: Chapter 27 on the child with cardiovascular dysfunction has major revisions to the latest guidelines for assessment and management of the most common heart disorders in children. Chapter 30 contains significant updates on seizures and epilepsy and cerebral abnormalities, including Chiari I and II malformations. Chapter 34 includes updates on Guillain-Barré syndrome, cerebral palsy, infant botulism, and respiratory management of neuromuscular conditions such as spinal muscular atrophy and muscular dystrophy. Unifying Principles Several unifying principles have guided the organizational structure of this book since its inception. These principles continue to strengthen the book with each revision to maintain a consistent approach throughout each chapter. The Family as the Unit of Care The child is an essential member of the family unit. Nursing care is most effective when it is delivered with the belief that the family is the patient. This belief permeates the book. The family is seen as a myriad of structures; each has the potential to provide a caring, supportive environment in which the child can grow, mature, and maximize his or her human potential. In addition to family- centered care being integrated into every chapter, an entire chapter is devoted to understanding the family as the core focus in 46 children's lives. Another chapter discusses the social, cultural, and religious influences on family beliefs. Separate sections in yet another chapter deal in depth with family communication and family assessment. The impact of illness, hospitalization, home care, and the death of a child are covered extensively in three additional chapters. The needs of the family are emphasized throughout the text under Nursing Care Management, with a separate section on family support. Numerous Family-Centered Care boxes are included to assist nurses in understanding and providing helpful information to families. An Integrated Approach to Development Children are not small adults but are special individuals with unique minds, bodies, and needs. No book on pediatric nursing is complete without extensive coverage of communication, nutrition, play, safety, dental care, sexuality, sleep, self-esteem, and, of course, parenting. Nurses promote the healthy expression of development and need to understand how this is observed in children at different ages and stages. Effective parenting depends on the parents' knowledge of development, and it is often the nurse's responsibility to provide parents with a developmental awareness of their children's needs. For these reasons, coverage of the many dimensions of childhood is integrated within each developmental- stage chapter, rather than being presented in a separate chapter. Safety concerns, for instance, are very different for a toddler than for an adolescent. Sleep needs change with age, as do nutritional needs. As a result, the units on each stage of childhood contain complete information on all these subjects as they relate to the specific age. Using the integrated approach, students gain an appreciation for the unique characteristics and needs of children at every age and stage of development. Focus on Wellness and Illness: Child, Family, and Community In a pediatric nursing text, a focus on illness is expected. Children become ill, and nurses typically are involved in helping children get well. However, it is not sufficient to prepare students to care 47 primarily for sick children. First, health is more than the absence of disease. Being healthy is being whole in mind, body, and spirit; therefore the majority of the first half of the book is devoted to discussions that promote physical, psychosocial, mental, and spiritual wellness. Much emphasis is placed on anticipatory guidance of parents to prevent injury or illness in the child. Second, more than ever, health care is prevention focused. The objectives set forth in Healthy People 2020 clearly establish a health care agenda in which solutions to medical/social problems lie in preventive strategies. Competent nursing care flows from this knowledge and is enhanced by an awareness of childhood development, family dynamics, and communication skills. Nursing Care Although this text incorporates information from numerous disciplines (e.g., medicine, pathophysiology, pharmacology, nutrition, psychology, sociology), its primary purpose is to provide information on the nursing care of children and families. Discussions of disorders conclude with a section on Nursing Care Management. Although many aspects of the nursing care of children and families have changed significantly over the last few decades, the focus must continue to be on the quality of care. For the quality of care to be maintained, pediatric nurses must be proactive in staying informed about the strength of evidence that supports specific nursing practices. The Nursing Care Management sections are designed to provide the latest evidence for the implementation of evidence-based nursing practice. In addition, all of the nursing care plans have been updated to current practices and include case studies to provide students with real examples to demonstrate critical thinking skills as they develop their own care plans. Critical Role of Research and Evidence- Based Practice This eleventh edition is the product of an extensive review of the literature published since the book was last revised. In addition, Research Focus boxes provide the student with a concise discussion 48 of the latest research on a given topic. So that information is accurate and current, most citations are less than 5 years old, and almost every chapter has entries within 1 year of publication. Examples of current cutting-edge information include recommendations from the American Academy of Pediatrics on immunizations and media use. The chapter on pain reflects the latest guidelines from the Agency for Healthcare Research and Quality (AHRQ), formerly known as the Agency for Health Care Policy and Research (AHCPR), and the American Pain Society. The discussions on skin care reflect the AHRQ's guidelines on pressure ulcers. The American Diabetes Association's classification of diabetes mellitus is included, as are the most recent treatment guidelines for asthma. Just as children and their families bring with them a value system and unique background that affect their role within the health care system, so too must each nurse bring to each child and family an individual set of characteristics and values that will affect their relationship. Although we have attempted to present a total picture of the child in each age-group, both in wellness and in illness, no one child, family, or nurse will be found in this book. We hope that each page, chapter, and unit builds a foundation on which the nurse can begin to construct an ideal of comprehensive, atraumatic, and individualized nursing care for infants, children, adolescents, and their families. 49 Special Features Much effort has been directed toward making this book easy to teach from and, more important, easy to learn from. In this edition, the following features have been included to benefit educators, students, and practitioners. Applying Evidence to Practice boxes are new specialty boxes throughout the text outlining up-to-date procedures to show best practice and focus on applying evidence. Atraumatic Care boxes emphasize the importance of providing competent care without creating undue physical and psychologic distress. Although many of the boxes provide suggestions for managing pain, atraumatic care also considers approaches to promote self- esteem and prevent embarrassment. Concepts have been added to the beginning of each chapter to focus student attention on unique principles found in each chapter as well as aid students using concept-based curriculum, system-focused curriculum, or a hybrid approach. Community and Home Health Considerations boxes address issues that expand to the community, such as increasing immunization rates, preventing lead poisoning, or decreasing smoking among teens. Critical Thinking 50 Case Study boxes have been revised in this edition to describe brief scenarios of the child-family-nurse interaction that depict real-life clinical situations. From the synthesis of the topical content and a critical analysis of possible options, the reader chooses the best intervention and learns to make clinical judgments. A rationale is offered for the correct answer, and explanations are given for the incorrect options at the end of the chapter. Cultural Considerations boxes integrate concepts of culturally sensitive care throughout the text. Their emphasis is on the clinical application of the information, whether it focuses on toilet training or on male or female circumcision. Drug Alert boxes highlight critical drug safety concerns for better therapeutic management. Emergency Treatment boxes enable the reader to quickly learn interventions for crisis situations. Family-Centered Care boxes present issues of special significance to families who have a child with a particular disorder. This feature is another method of highlighting the needs or concerns of families that should be addressed when family-centered care is provided. Nursing Alert boxes call the reader's attention to considerations that if ignored could lead to a deteriorating or emergency situation. Key assessment data, risk factors, and danger signs are among the kinds of information included. Nursing Care Guidelines boxes summarize important nursing interventions for a variety of situations and conditions. Nursing Care Plan boxes include expected patient outcomes and rationales for the included nursing interventions that may not be immediately 51 evident to the student. The care plans include a case study that represents a “real” patient and family to demonstrate the principles of nursing care plans and how they are used to organize care. Nursing Tip boxes present handy information of a nonemergency nature that makes patients more comfortable and the nurse's job a little easier. Pathophysiology Review boxes have been revised in this edition to provide the student with a visual representation of the effects of the disease process on the child. These illustrations provide knowledge required for the nurse to implement appropriate evidence-based nursing interventions and provide independent care, as well as collaborative care with other health care professionals. Quality Patient Outcomes boxes are added throughout the text to provide a framework for measuring nursing care performance. Nursing- sensitive outcome measures are integrated into the outcome indicators used throughout the book. Research Focus boxes review new evidence on important topics in a concise way. Translating Evidence into Practice boxes have been completely revised in this edition to focus the reader's attention on application of both research and critical thought processes to support and guide the outcomes of nursing care and to provide measurable outcomes that nurses can use to validate their unique role in the health care system. Numerous pedagogic devices that enhance student learning have been retained from previous editions: More than 100 COLOR PHOTOGRAPHS are included in this edition to reflect the latest in nursing care. Anatomic drawings are easy to follow, with color appropriately used to illustrate 52 important aspects, such as saturated and desaturated blood. New figures reflecting a PATHOPHYSIOLOGY REVIEW of various disorders have been added throughout the book. As an example, the full-color heart illustrations in Chapter 27 clearly depict congenital cardiac defects and associated hemodynamic changes. A functional and attractive FULL-COLOR DESIGN visually enhances the organization of each chapter, as well as the special features. An INDEX, detailed and cross-referenced, allows readers to quickly access discussions. KEY TERMS are highlighted throughout each chapter to reinforce student learning. BLOOD PRESSURE LEVELS on the inside back cover provide information nurses refer to often. Hundreds of TABLES and BOXES highlight key concepts and nursing interventions. 53 Acknowledgments This eleventh edition of Wong's Nursing Care of Infants and Children brings with it new contributors to the book. To continue the Wong legacy of excellence in nursing education, we have joined together numerous contributors with diverse expert nursing backgrounds to continue the commitment to providing the latest state-of-the-art information on pediatric nursing practice. We are grateful to the many nursing faculty members, practitioners, and students who have offered their comments, recommendations, and suggestions. We are grateful to the many reviewers who brought constructive criticism, suggestions, and clinical expertise to this edition. We could not have completed the enormous task of updating and adding information without the dedication of these special people. No book is ever a reality without the dedication and perseverance of the editorial staff. Although it is impossible to list every individual at Elsevier who has made exceptional efforts to produce this text, we are especially grateful to Heather Bays, whose commitment to pediatric nursing education over the years is reflective of outstanding editorial staff. She is passionate about her work, and her commitment to the Wong textbooks is noted in all she does. We want to thank Sandra Clark for all her support, and a special thanks also to Tracey Schriefer for her commitment to excellence. Finally, we thank our families and children for the unselfish love and endless patience that allows us to devote such a large portion of our lives to our careers. Marilyn J. Hockenberry Cheryl C. Rodgers 54 SECTION I Children, Their Families, and the Nurse OUTLINE 1 Perspectives of Pediatric Nursing 2 Social, Cultural, Religious, and Family Influences on Child Health Promotion 3 Hereditary Influences on Health Promotion of the Child and Family 55 1 Perspectives of Pediatric Nursing Marilyn J. Hockenberry CONCEPTS Family-Centered Care Atraumatic Care Clinical Reasoning Nursing Process Research and Evidence-Based Practice Quality Outcome Measures 56 Health Care for Children The major goal for pediatric nursing is to improve the quality of health care for children and their families. In 2016 almost 74 million children 0 to 17 years old lived in the United States, making up 24% of the population (Federal Interagency Forum on Child and Family Statistics, 2017). The health status of children in the United States has improved in a number of areas, including increased immunization rates for all children, decreased adolescent birth rate, and improved child health outcomes. The 2017 America's Children in Brief—Indicators of Well-Being reveals that preterm births increased slightly in 2015, after a continuous decline since 2007. Average mathematics scores for fourth- and eighth-grade students decreased, and the violent crime victimization rate among youth decreased during the last 20 years. Although the number of children living in poverty decreased slightly in 2015, overall the rate remains high at 20%. The percentage of children with at least one parent employed full time year remained steady at 75% in 2015 (see Research Focus box) (Federal Interagency Forum on Child and Family Statistics, 2017). Research Focus National Children's Study The National Children's Study is the largest prospective, long-term 57 study of children's health and development conducted in the United States. The study is designed to follow 100,000 children and their families from birth to 21 years old to understand the link between children's environments and their physical and emotional health and development (Duncan, Kirkendall, & Citro, 2014). Researchers hope that a study of this magnitude will provide information on innovative interventions for families, children, and health care providers to eradicate unhealthy diets, dental caries, and childhood obesity and to bring a significant reduction in violence, injury, substance abuse, and mental health disorders among the nation's children. This study supports the Healthy People 2020 primary goals to increase the quality and years of healthy life and eliminate health disparities related to race, ethnicity, and socioeconomic status (US Department of Health and Human Services, 2013). Millions of children and their families have no health insurance, which results in a lack of access to care and health promotion services. In addition, disparities in pediatric health care are related to race, ethnicity, socioeconomic status, and geographic factors (Flores & Lesley, 2014). Patterns of child health are shaped by medical progress and societal trends. Urgent priorities for health and health care of children in the United States are the focus for action toward new policy priorities (Box 1.1). Box 1.1 Health and Health Care Priorities for American Children Poverty Hunger Lack of health insurance Child abuse and neglect Overweight and obesity Firearm deaths and injuries Mental health Racial and ethnic disparities 58 Immigration Adapted from Flores, G., & Lesley, B. (2014). Children and US federal policy on health and health care: Seen but not heard. JAMA Pediatrics, 168(12), 1155-1163. Health Promotion Child health promotion provides opportunities to reduce differences in current health status among members of different groups and to ensure equal opportunities and resources to enable all children to achieve their fullest health potential. The Healthy People 2020 Leading Health Indicators (Box 1.2) provide a framework for identifying essential components for child health promotion programs designed to prevent future health problems in our nation's children. Bright Futures is a national health promotion initiative with a goal to improve the health of our nation's children (Bright Futures, 2016). Major themes of the Bright Futures guideline are promoting family support, child development, mental health, and healthy nutrition that leads to healthy weight, physical activity, oral health, healthy sexual development and sexuality, safety and injury prevention, and the importance of community relationships and resources.* Throughout this book, developmentally appropriate health promotion strategies are discussed. Key examples of child health promotion themes essential for all age- groups include promoting development, nutrition, and oral health. Bright Futures recommendations for preventive health care during infancy, early childhood, and adolescence are found in Chapters 7, 10, 12, 13, 15, and 17. Box 1.2 Healthy People 2020 Goals Increase quality and length of healthy life Eliminate health disparities 59 Leading Health Indicators Physical activity Overweight and obesity Tobacco use Substance abuse Responsible sexual behavior Mental health Injury and violence Environmental quality Immunization Access to health care From US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2013). Healthy People 2020. Retrieved from http://www.healthypeople.gov/ Development Health promotion integrates surveillance of the physical, psychologic, and emotional changes that occur in human beings between birth and the end of adolescence. Developmental processes are unique to each stage of development, and continuous screening and assessment are essential for early intervention when problems are found. The most dramatic time of physical, motor, cognitive, emotional, and social development occurs during infancy. Interactions between the parent and infant are central to promoting optimal developmental outcomes and are a key component of infant assessment. During early childhood, early identification of developmental delays is critical for establishing early interventions. Anticipatory guidance strategies ensure that parents are aware of the specific developmental needs of each developmental stage. Ongoing surveillance during middle childhood provides opportunities to strengthen cognitive and emotional attributes, communication skills, self-esteem, and independence. Recognition that adolescents differ greatly in their physical, social, and emotional maturity is important for surveillance throughout this developmental period. An important example for health promotion during early child development is to be aware of changing recommendations that 60 address the fast-changing world of technology in our society. An important example is the changes in the latest American Academy of Pediatrics (2016) policy statement on screen viewing by infants and children. New guidelines for screen viewing (laptop or phone) shift the importance from what is on the screen to who is viewing the information with the young child (American Academy of Pediatrics, 2016). For infants less than 18 months of age, no screen time is recommended except for video calling with a grandparent or loved one. Parents should be advised to use technology sparingly before 5 years of age and to always participate during screen-time viewing. Nutrition Nutrition is an essential component for healthy growth and development. Human milk is the preferred form of nutrition for all infants. Breastfeeding provides the infant with micronutrients, immunologic properties, and several enzymes that enhance digestion and absorption of these nutrients. A recent resurgence in breastfeeding has occurred as a result of the education of mothers and fathers regarding its benefits and increased social support. Children establish lifelong eating habits during the first 3 years of life, and the nurse is instrumental in educating parents on the importance of nutrition. Most eating preferences and attitudes related to food are established by family influences and culture. During adolescence, parental influence diminishes and the adolescent makes food choices related to peer acceptability and sociability. Occasionally these choices are detrimental to adolescents with chronic illnesses such as diabetes, obesity, chronic lung disease, hypertension, cardiovascular risk factors, and renal disease. Families that struggle with lower incomes, homelessness, and migrant status generally lack the resources to provide their children with adequate food intake, nutritious foods such as fresh fruits and vegetables, and appropriate protein intake (Flores & Lesley, 2014). The result is nutritional deficiencies with subsequent growth and developmental delays, depression, and behavior problems. Oral Health 61 Oral health is an essential component of health promotion throughout infancy, childhood, and adolescence. Preventing dental caries and developing healthy oral hygiene habits must occur early in childhood. Dental caries has been recommended for decades as a significant yet preventable health problem for children (Clark, Kent, & Jackson, 2015). Children in racial or cultural minority groups,experience disparities in oral health care and are much more likely to have dental disease. In children ages 2 to 8 years, Hispanic and non-Hispanic black children are twice as likely to experience any dental caries in primary teeth compared with non-Hispanic white children (Dye, Thornton-Evans, Li, et al., 2015). Preschoolers of low-income families are twice as likely to develop tooth decay and only half as likely to visit the dentist as other children. Early childhood caries is a preventable disease, and nurses play an essential role in educating children and parents about practicing dental hygiene, beginning with the first tooth eruption; drinking fluoridated water, including bottled water; and instituting early dental preventive care. Oral health care practices established during the early years of development prevent destructive periodontal disease and dental decay. Childhood Health Problems Changes in modern society, including advancing medical knowledge and technology, the proliferation of information systems, struggles with insurance disparities, economically troubled times, and various changes and disruptive influences on the family, are leading to significant medical problems that affect the health of children. Problems that can negatively affect a child's development include poverty, violence, aggression, noncompliance, school failure, and adjustment to parental separation and divorce. In addition, mental health issues cause challenges in childhood and adolescence. Recent concern has focused on groups of children who are at highest risk, such as children born preterm or with very low birth weight (VLBW) or low birth weight (LBW), children attending child care centers, children who live in poverty or are homeless, children of immigrant families, and children with chronic medical and psychiatric illness and disabilities. In addition, these children and their families face multiple barriers to adequate health, dental, 62 and psychiatric care. A perspective of several health problems facing children and the major challenges for pediatric nurses is discussed in the following sections. Obesity and Type 2 Diabetes Childhood obesity, the most common nutritional problem among American children, is increasing in epidemic proportions (Martin, Saunders, Shenkin, et al., 2014). Obesity in children and adolescents is defined as a body mass index (BMI) at or greater than the 95th percentile for youth of the same age and gender. Overweight is defined as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex. Over 30% of America's children are overweight, and 17% are obese (Flores & Lesley, 2014). Increasing evidence associates maternal obesity as a major influence on offspring health during childhood and in adult life (Godfrey, Reynolds, Prescott, et al., 2016). An optimal nutritional and microbial environment during pregnancy may reduce the risk of infants being obese or overweight during early life (Garcia- Mantrana & Collado, 2016). Lack of physical activity related to limited resources, unsafe environments, and inconvenient play and exercise facilities, combined with easy access to television and video games, increases the incidence of obesity among low-income, minority children. Overweight youth have increased risk for cardiometabolic changes (a cluster of cardiovascular factors that include hypertension, altered glucose metabolism, dyslipidemia, and abdominal obesity) in the future (Weiss, Bremer, & Lustig, 2013) (Fig. 1.1). The US Department of Health and Human Services (2013) suggests that nurses focus on prevention strategies to reduce the incidence of overweight children from the current 20% in all ethnic groups to less than 6%. Emphasis is on preventive strategies that start in infancy and even in the prenatal period. Lifestyle interventions show promise in preventing obesity and decreasing occurrence if targeted at children 6 to 12 years old (Martin, Saunders, Shenkin, et al., 2014). 63 FIG. 1.1 The American culture's intake of high-caloric, fatty food contributes to obesity in children. Childhood Injuries Injuries are the most common cause of death and disability to children in the United States (Centers for Disease Control and Prevention, 2016) (Table 1.1). Mortality rates for suicide, poisoning, and falls rose substantially over the past decade. Other unintentional injuries (head injuries, drowning, burns, and firearm accidents) take the lives of children every day. Implementing programs of accident prevention and health promotion could prevent many childhood injuries and fatalities. TABLE 1.1 Mortality From Leading Types of Unintentional Injuries, United States* AGE (YEARS) Type of Injury 5 mm) containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets are generated 608 from the source person primarily during coughing, sneezing, or talking and during procedures such as suctioning and bronchoscopy. Transmission requires close contact between source and recipient persons because droplets do not remain suspended in the air and generally travel only short distances, usually 3 feet or less, through the air. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission. Droplet Precautions apply to any patient with known or suspected infection with pathogens that can be transmitted by infectious droplets (see Box 6.1). Contact Precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when turning or bathing patients. Direct- contact transmission also can occur between two patients (e.g., by hand contact). Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment. Contact Precautions apply to specified patients known or suspected to be infected or colonized with microorganisms that can be transmitted by direct or indirect contact. Nursing Alert The most common piece of medical equipment, the stethoscope, can be a potent source of harmful microorganisms and nosocomial infections. Consider also the keyboard and desktop as potential sources. Nurses caring for young children are frequently in contact with body substances, especially urine, feces, and vomitus. Nurses need to exercise judgment concerning those situations when gloves, gowns, or masks are necessary. For example, wear gloves and possibly gowns for changing diapers when there are loose or explosive stools. Otherwise, the plastic lining of disposable diapers provides a sufficient barrier between the hands and body substances and gloves are adequate. 609 Antimicrobial-resistant organisms are causing increasing numbers of HAIs. In hospitals, patients are the most significant sources of methicillin-resistant Staphylococcus aureus (MRSA), and the main mode of transmission is patient-to-patient transmission via the hands of a health care provider. Hand washing is the most critical infection control practice. During feedings, wear gowns if the child is likely to vomit or spit up, which often occurs during burping. When wearing gloves, wash the hands thoroughly after removing the gloves because gloves fail to provide complete protection. The absence of visible leaks does not indicate that gloves are intact. Another essential practice of infection control is that all needles (uncapped and unbroken) are disposed of in a rigid, puncture- resistant container located near the site of use. Consequently, these containers are installed in each patient's room. Because children are naturally curious, extra attention is needed in selecting a suitable type of container and a location that prevents access to the discarded needles (Fig. 6.1). The use of needleless systems allows secure syringe or intravenous (IV) tubing attachment to vascular access devices without the risk of needle stick injury to the child or nurse. FIG. 6.1 To prevent needlestick injuries, used needles (and other sharp instruments) are not capped or broken and are disposed of in a rigid, puncture- 610 resistant container located near site of use. Note placement of container to prevent children's access to contents. Immunizations* One of the most dramatic advances in pediatrics has been the decline of infectious diseases during the twentieth century because of the widespread use of immunization for preventable diseases. This trend has continued into the twenty-first century with the development of newer vaccines. Although many of the immunizations can be given to individuals of any age, the recommended primary schedule begins during infancy and, with the exception of boosters, is completed during early childhood. This section includes a discussion of childhood immunizations for diphtheria, tetanus, and acellular pertussis (DTaP); poliovirus; measles, mumps, and rubella (MMR); Haemophilus influenzae type b (Hib); hepatitis B virus (HBV); hepatitis A virus (HAV); meningococcal; pneumococcal conjugate vaccine (PCV); influenza (and H1N1); varicella-zoster virus (VZV; chickenpox); rotavirus; and human papillomaviruses. Selected vaccines generally reserved for children considered at high risk for the disease are discussed here and as appropriate throughout the text. To facilitate an understanding of immunizations, key terms are listed in Box 6.2. Although in this discussion the terms vaccination and immunization are used interchangeably in reference to active immunization, they are not synonymous because the administration of an immunobiologic such as a vaccine cannot automatically be equated with the development of adequate immunity. Box 6.2 Key Immunization Terms Immunization—Inclusive term denoting the process of inducing or providing active or passive immunity artificially by administering an immunobiologic 611 Immunity—An inherited or acquired state in which an individual is resistant to the occurrence or the effects of a specific disease, particularly an infectious agent Natural immunity—Innate immunity or resistance to infection or toxicity Acquired immunity—Immunity from exposure to the invading agent, either bacteria, virus, or toxin Active immunity—A state where immune bodies are actively formed against specific antigens, either naturally by having had the disease clinically or subclinically or artificially by introducing the antigen into the individual Passive immunity—Temporary immunity obtained by transfusing immunoglobulins or antitoxins either artificially from another human or an animal that has been actively immunized against an antigen or naturally from the mother to the fetus via the placenta Antibody—A protein, found mostly in serum, that is formed in response to exposure to a specific antigen Antigen—A variety of foreign substances, including bacteria, viruses, toxins, and foreign proteins, that stimulate the formation of antibodies Attenuate—Reduce the virulence (infectiousness) of a pathogenic microorganism by such measures as treating it with heat or chemicals or cultivating it on a certain medium Immunobiologic—Antigenic substances (e.g., vaccines and toxoids) or antibody-containing preparations (e.g., globulins and antitoxins) from human or animal donors, used for active or passive immunization or therapy Vaccine—A suspension of live (usually attenuated) or inactivated microorganisms (e.g., bacteria, viruses, or rickettsiae) or fractions of the microorganism administered to induce immunity and prevent infectious disease or its sequelae Toxoid—A modified bacterial toxin that has been made nontoxic but retains the ability to stimulate the formation of antitoxin Antitoxin—A solution of antibodies (e.g., diphtheria antitoxin, botulinum antitoxin) derived from the serum of animals immunized with specific antigens and used to confer passive 612 immunity and for treatment Immunoglobulin (Ig) or intravenous immunoglobulin (IVIG)—A sterile solution containing antibodies from large pools of human blood plasma; primarily indicated for routine maintenance of immunity of certain immunodeficient persons and for passive immunization against measles and hepatitis A Specific immunoglobulins—Special preparations obtained from blood plasma from donor pools preselected for a high antibody content against a specific antigen (e.g., hepatitis B immunoglobulin, varicella zoster immunoglobulin, rabies immunoglobulin, tetanus immunoglobulin, and cytomegalovirus immunoglobulin); as with Ig and IVIG, do not transmit hepatitis B virus, human immunodeficiency virus, or other infectious diseases Vaccination—Originally referred to inoculation with vaccinia smallpox virus to make a person immune to smallpox; currently denotes physical act of administering any vaccine or toxoid Herd immunity—A condition in which the majority of the population community is vaccinated and the spread of certain diseases is stopped because the population that has been vaccinated protects those in the same population who are unvaccinated Monovalent vaccine—Vaccine designed to vaccinate against a single antigen or organism Conjugate vaccine—A carrier protein with proven immunologic potential combined with a less antigenic polysaccharide antigen to enhance the type and magnitude of the immune response (e.g., Haemophilus influenzae type b [Hib]) Combination vaccine—Combination of multiple vaccines into one parenteral form Polyvalent vaccine—Vaccine designed to vaccinate against two or more antigens or organisms (e.g., inactivated poliovirus vaccine [IPV]) Cocooning—strategy of protecting infants from pertussis by vaccinating all persons who come in close contact with the infant, including the mother, grandparents, and health care 613 workers. Schedule for Immunizations In the United States, two organizations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention and the Committee on Infectious Diseases of the American Academy of Pediatrics, govern the recommendations for immunization policies and procedures. In Canada, recommendations are from the National Advisory Committee on Immunization under the authority of the Minister of Health and Public Health Agency of Canada. The policies of each committee are recommendations, not rules, and they change as a result of advances in the field of immunology. Nurses need to be knowledgeable about the purpose of each organization, view immunization practices in light of the needs of each individual child and the community, and keep informed of the latest advances and changes in policy. The recommended age for beginning primary immunizations of infants is at birth or within 2 weeks of birth. Children born preterm should receive the full dose of each vaccine at the appropriate chronologic age. A recommended catch-up schedule for children not immunized during infancy is available at the Centers for Disease Control and Prevention website (http://www.cdc.gov/vaccines/schedules/downloads/child/catchup- schedule-pr.pdf). Immunization recommendation schedules for Canadian children are available at http://www.phac- aspc.gc.ca/im/is-cv/index-eng.php. Children who began primary immunization at the recommended age but fail to receive all the doses do not need to begin the series again but instead receive only the missed doses. For situations in which there is doubt that the child will return for immunization according to the optimum schedule, HBV vaccine (HepB), DTaP, IPV (poliovirus vaccine), MMR, varicella, and Hib vaccines can be administered simultaneously at separate injection sites. Parenteral vaccines are given in separate syringes in different injection sites (American Academy of Pediatrics, 2015). Recommendations for Routine Immunizations* 614 Hepatitis B Virus HBV is a significant pediatric disease because HBV infections that occur during childhood and adolescence can lead to fatal consequences from cirrhosis or liver cancer during adulthood. Up to 90% of infants infected perinatally and 25% to 50% of children infected before age 5 years become chronically infected (American Academy of Pediatrics, 2015). It is recommended that newborns receive HepB before hospital discharge if the mother is hepatitis B surface antigen (HBsAg) negative. Monovalent HepB should be given as the birth dose, whereas combination vaccine containing HepB may be given for subsequent doses in the series. Both full- term and preterm infants born to mothers whose HBsAg status is positive or unknown should receive HepB and hepatitis B immune globulin (HBIG), 0.5 ml, within 12 hours of birth at two different injection sites. Because the immune response to HepB is not optimum in newborns weighing less than 2000 grams (4.4 pounds), the first HepB dose should be given to such infants at a chronologic age of 1 month, as long as the mother's HBsAg status is negative (American Academy of Pediatrics, 2015). In the event that the preterm infant is given a dose at birth, the current recommendation is that the infant be given the full series (three additional doses) at 1, 2, and 6 months of age. The American Academy of Pediatrics (2015) also encourages immunization of all children by age 11 years. The vaccine is given intramuscularly in the vastus lateralis in newborns or in the deltoid for older infants and children. Regardless of age, avoid the dorsogluteal site because it has been associated with low antibody seroconversion rates, indicating a reduced immune response. No data exist regarding the seroconversion when the ventrogluteal site is used. The vaccine can be safely administered simultaneously at a separate site with DTaP, MMR, and Hib vaccines. Hepatitis A Virus Hepatitis A has been recognized as a significant child health problem, particularly in communities with unusually high infection rates. HAV is spread by the fecal-oral route and from person-to- person contact, by ingestion of contaminated food or water, and, rarely, by blood transfusion. The illness has an abrupt onset, with fever, malaise, anorexia, nausea, abdominal discomfort, dark urine, 615 and jaundice being the most common clinical signs of infection. In children under 6 years of age, who represent approximately one- third of all cases of hepatitis A, the disease may be asymptomatic, and jaundice is rarely evident. HepA vaccine is now recommended for all children beginning at age 1 year (i.e., 12 months to 23 months). The second dose in the two-dose series may be administered no sooner than 6 months after the first dose. Since the implementation of widespread childhood HepA vaccination, infection rates among children ages 5 to 14 years have declined significantly. Diphtheria Although cases of diphtheria are rare in the United States, the disease can result in significant morbidity. Respiratory manifestations include respiratory nasopharyngitis or obstructive laryngotracheitis with upper airway obstruction. The cutaneous manifestations of the disease include vaginal, otic, conjunctival, or cutaneous lesions, which are primarily seen in urban homeless persons and in the tropics (American Academy of Pediatrics, 2015). Administer a single dose of equine antitoxin intravenously to the child with clinical symptoms because of the often fulminant progression of the disease (American Academy of Pediatrics, 2015). Diphtheria vaccine is commonly administered (1) in combination with tetanus and pertussis vaccines (DTaP) or DTaP and Hib vaccines for children younger than 7 years of age, (2) in combination with a conjugate H. influenzae type B vaccine, (3) in a combined vaccine with tetanus (DT) for children younger than 7 years of age who have some contraindication to receiving pertussis vaccine, (4) in combination with tetanus and acellular pertussis (Tdap) for children 11 years and older, or (5) as a single antigen when combined antigen preparations are not indicated. Although the diphtheria vaccine does not produce absolute immunity, protective antitoxin persists for 10 years or more when given according to the recommended schedule, and boosters are given every 10 years for life (see following discussion for adolescent diphtheria and acellular pertussis and tetanus toxoid recommendation). Several vaccines contain diphtheria toxoid (e.g., Hib, meningococcal, pneumococcal), but this does not confer immunity to the disease. 616 Tetanus Three forms of tetanus vaccine—tetanus toxoid, tetanus immunoglobulin (TIG) (human), and tetanus antitoxin (equine antitoxin)—are available; however, tetanus antitoxin is no longer available in the United States. Tetanus toxoid is used for routine primary immunization, usually in one of the combinations listed for diphtheria, and provides protective antitoxin levels for approximately 10 years. Tetanus and diphtheria toxoids along with acellular pertussis vaccine (Tdap) are now recommended for persons ages 11 to 12 years who have completed the recommended DTaP/DTP vaccine series but have not received the tetanus (Td) booster dose. Adolescents 13 to 18 years of age who have not received the Td/Tdap booster should receive a single Tdap booster, provided the routine DTaP/DTP childhood immunization series has been previously received. In addition, children ages 7 to 10 years who are not fully vaccinated for pertussis (i.e., did not receive 5 doses of DTaP or 4 doses of DTaP with the fourth dose being administered on or after the fourth birthday) should receive a dose of Tdap (American Academy of Pediatrics, 2015). It is recommended that children receive subsequent Td boosters every 10 years (American Academy of Pediatrics, 2015). Boostrix (Tdap) is currently licensed for persons 10 years of age (including those ≥65 years of age) and older, whereas Adacel (Tdap) is licensed for individuals 10 to 64 years of age. For wound management, passive immunity is available with TIG. Persons with a history of two previous doses of tetanus toxoid can receive a booster dose of the toxoid. Separate syringes and different sites are used when tetanus toxoid and TIG are given concurrently. For children over 7 years who require wound prophylaxis, tetanus immunization may be accomplished by administering Td (adult-type diphtheria and tetanus toxoids). If TIG is not available, the equine antitoxin (not available in the United States) may be administered after appropriate testing for sensitivity. The antitoxin is administered in a separate syringe and at a separate intramuscular site if given concurrently with tetanus toxoid. Pertussis Pertussis vaccine is recommended for all children 6 weeks through 617 6 years of age (up to the seventh birthday) who have no neurologic contraindications to its use. Concerns over outbreaks of the disease in the past decade have prompted discussion about vaccinating infants and adults. Many cases of pertussis have occurred in children less than 6 months or persons over 7 years, both groups falling in the category for which pertussis immunization previously was not recommended. The tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) is now recommended at ages 11 to 12 years for persons who have completed the DTaP/DTP childhood series. The Tdap is also recommended for adolescents 13 to 18 years old who have not received a tetanus booster (Td) or Tdap dose and have completed the childhood DTaP/DTP series. When the Tdap is used as a booster dose, it may be administered regardless of the interval from the previous tetanus, diphtheria, and pertussis-containing vaccine. Children ages 7 through 10 years who are not fully vaccinated for pertussis (i.e., did not receive 5 doses of DTaP or 4 doses of DTaP with the fourth dose being administered on or after the fourth birthday) should receive a dose of Tdap (American Academy of Pediatrics, 2015) (see discussion in Tetanus). The Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists have recommended that pregnant adolescents and women who are not protected against pertussis receive the Tdap vaccine optimally between 27 and 36 weeks of gestation or postpartum before discharge from the hospital; breastfeeding is not a contraindication to Tdap vaccination (Centers for Disease Control and Prevention, 2013a). The concept of cocooning has been promoted since 2006 to reduce the spread of pertussis to vulnerable infants. Cocooning involves the strategy of vaccinating pregnant women during or after pregnancy, as well as all persons who will have close contact with the infants (including health care workers, fathers, and adults [especially those ages 65 years and older]) (Blain, Lewis, Banerjee, et al., 2016). Cocooning can prevent pertussis in vulnerable infants; however, actual implantation of the cocooning strategy among all family members is difficult (Blain, Lewis, Banerjee, et al., 2016). Currently, two forms of pertussis vaccine are available in the United States. The whole-cell pertussis vaccine is prepared from inactivated cells of Bordetella pertussis and contains multiple antigens. In contrast, the acellular pertussis vaccine contains one or 618 more immunogens derived from the B. pertussis organism. The highly purified acellular vaccine is associated with fewer local and systemic reactions than those occurring with the whole-cell vaccine in children of similar age. The acellular pertussis vaccine is recommended by the American Academy of Pediatrics (2015) for the first three immunizations and is usually given at 2, 4, and 6 months of age with diphtheria and tetanus (DTaP). Several forms of acellular pertussis vaccine are currently licensed for use in infants: Daptacel, Pediatrix, Kinrix (DTaP and IPV), and Infanrix (diphtheria, tetanus toxoid, and acellular pertussis conjugate). Pentacel is licensed for use in infants 4 weeks old and older; in addition to acellular pertussis, diphtheria, and tetanus, this vaccine also contains inactivated poliovirus (IPV) and Hib conjugate. Either the acellular or whole-cell vaccine may be given for the fourth and fifth doses, but the acellular is preferred. It is also recommended that the first three DTaP vaccinations be from the same manufacturer. The fourth dose may be from a different manufacturer. The child who has received one or more whole-cell vaccines may complete the series of five with the acellular vaccine. Health care workers who may be susceptible to pertussis as a result of waning immunity and who have potential exposure to children or adults with pertussis should receive a single dose of Tdap (if not previously vaccinated with same) and take the necessary protective precautions against droplet contamination (i.e., wear procedural or surgical masks and practice hand washing). The diagnosis of pertussis may be missed or delayed in unvaccinated infants, who often are seen with respiratory distress and apnea without the typical cough. Additional guidelines for prevention and treatment of pertussis among health care workers and close contacts can be found on the Centers for Disease Control and Prevention website: http://www.cdc.gov/vaccines/. Polio An all-IPV (inactivated poliovirus vaccine) schedule for routine childhood polio vaccination is now recommended for children in the United States. All children should receive four doses of IPV at 2 months, 4 months, 6 to 18 months, and 4 to 6 years of age (American Academy of Pediatrics, 2015). 619 The change from the exclusive use of oral polio vaccine (OPV) to the exclusive use of IPV is related to the rare risk of vaccine- associated polio paralysis (VAPP) from OPV. The exclusive use of IPV eliminates the risk of VAPP but is associated with an increased number of injections and increased cost. Since IPV usage was instituted in the United States in 2000, no new indigenously acquired cases of VAPP have occurred. Pediarix is a combination vaccine containing DTaP, hepatitis B, and IPV; this may be used as the primary immunization beginning at 2 months of age (American Academy of Pediatrics, 2015). Kinrix contains DTaP and IPV, and it may be used as the fifth dose in the DTaP series and the fourth dose in the IPV series in children ages 4 to 6 years whose previous vaccine doses have been with Infanrix and/or Pediarix for the first three doses and Infanrix for the fourth dose. As noted earlier, Pentacel is also licensed for use in infants 4 weeks old and older and contains DTaP, Hib, and inactivated poliovirus. Pediarix has been licensed for use in children as young as 6 weeks and contains DTaP, Hep B, and inactivated poliovirus. Measles The measles (rubeola) vaccine is given at 12 to 15 months of age. During the course of measles outbreaks, the vaccine can be given at 6 to 11 months of age, followed by a second inoculation after age 12 months. The second measles immunization is recommended at 4 to 6 years of age (at school entry) but may be given earlier provided that 4 weeks have elapsed since the administration of the previous dose. Revaccination should occur by 11 to 12 years of age if the measles vaccine was not administered at school entry (4 to 6 years). Any child who is vaccinated before 12 months of age should receive two additional doses beginning at 12 to 15 months and separated by at least 4 weeks (American Academy of Pediatrics, 2015). Revaccination should

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