Comprehensive Guide to Newborn care and Child Care in community

Posted on by Soumya Ranjan Parida
Comprehensive Guide to Newborn and Child Care: A Community Health Nursing Perspective

Comprehensive Guide to Newborn and Child Care

A Community Health Nursing Perspective

Essential knowledge for nursing students to provide optimal care for newborns and children in community settings

Newborn care in community health setting
A healthcare professional providing essential newborn care assessment in a community health setting

Table of Contents

1. Introduction to Newborn Care

Newborn care represents a critical component of community health nursing that directly impacts infant mortality and morbidity rates. Effective newborn care practices during the first 28 days of life are essential for ensuring optimal growth and development of infants. Community health nurses play a pivotal role in providing these services at the grassroots level, often being the first point of healthcare contact for many families.

In developing countries, approximately 3 million neonatal deaths occur annually, with most being preventable through proper newborn care interventions. The principles of essential newborn care focus on simple, cost-effective practices that can significantly reduce neonatal mortality and promote healthy development.

Community health nurses are uniquely positioned to implement newborn care guidelines through:

  • Home visits during antenatal and postnatal periods
  • Education on essential newborn care practices
  • Early identification of danger signs
  • Timely referrals to appropriate healthcare facilities
  • Community mobilization and awareness creation

2. Essential Newborn Care

Essential newborn care encompasses evidence-based practices that protect newborns during their most vulnerable period. These interventions are simple yet effective methods that community health nurses can implement or teach to caregivers.

2.1 Immediate Care After Birth

The first few minutes after birth are critical for establishing vital functions and preventing complications. The WHO recommends following the “Golden Minute” principle, which emphasizes immediate newborn care interventions within 60 seconds of birth.

Key Steps in Immediate Newborn Care

1
Dry the baby thoroughly – Immediately dry the entire body including the head using a clean, dry cloth to prevent heat loss.
2
Assess breathing – Observe chest movements and listen for crying. If not breathing, begin gentle stimulation.
3
Ensure skin-to-skin contact – Place the baby prone on mother’s chest/abdomen and cover both with a dry cloth.
4
Delayed cord clamping – Wait at least 1-3 minutes before clamping the umbilical cord.
5
Initiate early breastfeeding – Help mother initiate breastfeeding within the first hour.

APGAR Score Assessment

Sign 0 1 2
Appearance Blue/pale Body pink, extremities blue Completely pink
Pulse Absent <100 bpm >100 bpm
Grimace No response Grimace Cry/cough
Activity Limp Some flexion Active motion
Respiration Absent Slow/irregular Good cry

Evaluate at 1 and 5 minutes after birth. Score 7-10: Normal, 4-6: Moderate distress, 0-3: Severe distress.

Mnemonic: “STABLE”

Use this to remember essential components of immediate newborn care:

  • Sugar and Safe Care
  • Temperature
  • Airway
  • Blood Pressure
  • Lab Work
  • Emotional Support

2.2 Thermoregulation

Maintaining optimal body temperature is crucial for newborns as they have limited ability to regulate their own temperature. Hypothermia increases the risk of metabolic complications, while hyperthermia may indicate infection or environmental overheating.

Why Newborns Lose Heat Rapidly

  • • High surface area to body weight ratio
  • • Thin skin with minimal subcutaneous fat
  • • Limited ability to shiver
  • • Limited glycogen stores for heat production
  • • Immature thermal regulation centers

Four Mechanisms of Heat Loss

  • • Conduction: Direct contact with cold surfaces
  • • Convection: Air currents across baby’s skin
  • • Radiation: Heat loss to colder surrounding objects
  • • Evaporation: Moisture on skin converting to vapor

Critical Nursing Interventions for Thermoregulation

  • Maintain room temperature between 24-26°C
  • Use skin-to-skin contact (kangaroo mother care)
  • Delay bathing for at least 24 hours after birth
  • Cover baby’s head with a cap (30% of heat loss occurs from the head)
  • Pre-warm surfaces that will contact the newborn
  • Use radiant warmers for procedures requiring exposure
  • Monitor axillary temperature every 30 minutes until stable

2.3 Breastfeeding and Nutrition

Exclusive breastfeeding for the first six months is a cornerstone of optimal newborn care and development. Community health nurses play a vital role in supporting mothers to initiate and maintain successful breastfeeding practices.

Benefits of Breastfeeding

For the Baby:

  • Complete nutrition for first 6 months
  • Antibodies for infection prevention
  • Reduced risk of allergies and asthma
  • Lower incidence of sudden infant death syndrome
  • Promotes proper jaw and dental development
  • Improved cognitive development

For the Mother:

  • Promotes uterine contraction and reduces bleeding
  • Natural child spacing (LAM method)
  • Reduced risk of breast and ovarian cancer
  • Faster return to pre-pregnancy weight
  • Reduced risk of postpartum depression

Successful Breastfeeding Techniques

Correct Positioning and Attachment:

  1. Baby’s body should be aligned and turned completely toward mother
  2. Head and body should be in a straight line
  3. Baby’s nose should be opposite the nipple before latching
  4. Baby’s mouth should be wide open, taking in nipple and most of areola
  5. Lower lip should be turned outward
  6. More areola should be visible above than below the baby’s mouth
  7. Sucking should be slow, deep, with occasional pauses
Remember the 4 positions for breastfeeding:
  • Cradle position
  • Cross-cradle position
  • Football/clutch hold
  • Side-lying position

Mnemonic: “BREAST” Feeding Counseling

  • Benefits of breastfeeding
  • Risks of artificial feeding
  • Early initiation and exclusivity
  • Attachment and positioning
  • Supply maintenance
  • Troubleshooting common problems

2.4 Hygiene and Cord Care

Proper hygiene practices are essential components of newborn care that prevent infections and promote overall well-being. Umbilical cord care requires special attention to prevent omphalitis and other infections.

Umbilical Cord Care

WHO recommends dry cord care in clean environments:

  • • Keep the cord clean and dry
  • • Leave cord uncovered to air dry
  • • Fold diaper below cord to prevent contamination
  • • No application of substances unless medically indicated
  • • In high-risk settings, chlorhexidine 4% may be applied
  • • Normal cord separation occurs in 5-15 days

Warning Signs of Cord Infection:

  • Redness around the base
  • Foul-smelling discharge
  • Pus or bleeding
  • Delayed cord separation (>15 days)

Bathing and Skin Care

First Bath:

  • Delay first bath for at least 24 hours
  • Preserves vernix caseosa’s protective properties
  • Maintains temperature stability
  • Promotes colonization with beneficial bacteria

Routine Bathing:

  • 2-3 times per week is sufficient
  • Use plain water for first month
  • If soap is necessary, use mild, fragrance-free products
  • Keep bath time brief (5-10 minutes)
  • Use soft cloth for cleaning

Diaper Area Care:

  • Change diapers frequently
  • Clean with water or mild wipes
  • Allow area to dry completely
  • Apply barrier cream if needed

2.5 Immunization

Immunization is a critical component of newborn care and child health, providing protection against preventable diseases. Community health nurses are often responsible for administering vaccines and educating parents about immunization schedules.

Recommended Immunization Schedule for Newborns and Infants

Age Vaccine Disease Protection Route
Birth BCG
OPV-0
Hepatitis B (1st dose)		 Tuberculosis
Poliomyelitis
Hepatitis B		 Intradermal
Oral
Intramuscular
6 Weeks OPV-1
Pentavalent-1
Rotavirus-1
PCV-1		 Polio
DPT+HepB+Hib
Rotavirus diarrhea
Pneumococcal diseases		 Oral
Intramuscular
Oral
Intramuscular
10 Weeks OPV-2
Pentavalent-2
Rotavirus-2
PCV-2		 Polio
DPT+HepB+Hib
Rotavirus diarrhea
Pneumococcal diseases		 Oral
Intramuscular
Oral
Intramuscular
14 Weeks OPV-3
Pentavalent-3
Rotavirus-3
PCV-3
IPV		 Polio
DPT+HepB+Hib
Rotavirus diarrhea
Pneumococcal diseases
Polio		 Oral
Intramuscular
Oral
Intramuscular
Intramuscular
9 Months Measles-1
Vitamin A		 Measles
Vitamin A deficiency		 Subcutaneous
Oral

Note: Schedules may vary by country according to national immunization programs

Key Nursing Responsibilities in Immunization

Before Administration:

  • Check immunization card and due vaccines
  • Screen for contraindications
  • Maintain cold chain integrity
  • Explain procedure and expected reactions
  • Obtain informed consent

After Administration:

  • Monitor for immediate adverse reactions
  • Record vaccine details in child’s health card
  • Educate about possible side effects
  • Inform about next due date
  • Proper disposal of used equipment

3. Management of Common Neonatal Problems

Early identification and management of common neonatal problems are essential aspects of newborn care. Community health nurses should be equipped to recognize warning signs, provide initial management, and make appropriate referrals when necessary.

3.1 Neonatal Jaundice

Neonatal jaundice is the yellowish discoloration of the skin and sclera due to hyperbilirubinemia. It affects approximately 60% of full-term and 80% of preterm newborns.

Types of Neonatal Jaundice

Type Onset Cause
Physiological Day 2-3 Normal physiologic process, immature liver
Pathological Within 24 hours Blood group incompatibilities, hemolysis
Breastfeeding jaundice First week Insufficient intake, dehydration
Breast milk jaundice After first week Substances in breast milk affecting bilirubin clearance

Assessment and Detection

Kramer’s Rule: Visual assessment of jaundice progression

  1. Zone 1: Head and neck = ~5 mg/dL
  2. Zone 2: Upper trunk = ~10 mg/dL
  3. Zone 3: Lower trunk and thighs = ~12 mg/dL
  4. Zone 4: Arms and lower legs = ~15 mg/dL
  5. Zone 5: Palms and soles = >15 mg/dL

Note: Visual assessment is only a screening tool and should be confirmed with bilirubin measurement when available.

Management of Neonatal Jaundice in Community Setting

Mild Jaundice:

  • Frequent breastfeeding (8-12 times/day)
  • Expose to indirect sunlight for 15-20 mins twice daily
  • Monitor for progression
  • Follow-up within 24 hours

Moderate Jaundice:

  • Continue breastfeeding
  • Refer for serum bilirubin measurement
  • Consider home phototherapy if available
  • Daily follow-up

Severe Jaundice (Danger Signs):

  • Jaundice in first 24 hours
  • Palms and soles yellow
  • Lethargy or high-pitched cry
  • Persistent feeding problems
  • URGENT referral to hospital

Parent Education Points:

  • Recognize jaundice (yellowish skin, especially face and eyes)
  • Understand importance of frequent feeding
  • Know when to seek care (feeding problems, lethargy, high-pitched cry)
  • Understand the complications of severe untreated jaundice (kernicterus)
  • Follow recommended follow-up schedule

3.2 Neonatal Sepsis

Neonatal sepsis is a systemic infection occurring in the first 28 days of life and remains a significant cause of morbidity and mortality. Early recognition and prompt referral are critical aspects of newborn care in community settings.

Risk Factors

  • Maternal factors:
    • Prolonged rupture of membranes (>18h)
    • Maternal fever (>38°C)
    • Urinary tract infection
    • Chorioamnionitis
  • Neonatal factors:
    • Prematurity
    • Low birth weight
    • Male gender
    • Birth asphyxia
  • Environmental factors:
    • Unhygienic delivery practices
    • Unhygienic cord care
    • Poor hand hygiene

Clinical Manifestations – The “SEPSIS” Mnemonic

Skin changes:

  • Poor skin color (pale, cyanotic, mottled)
  • Rash or skin pustules
  • Umbilical redness or discharge

Eating problems:

  • Refusal to feed
  • Poor sucking
  • Vomiting

Persistent abnormal temperature:

  • Fever (>38°C)
  • Hypothermia (<36°C)
  • Temperature instability

Significant respiratory changes:

  • Fast breathing (>60 breaths/min)
  • Chest indrawing
  • Grunting

Irritability or lethargy:

  • Excessive crying
  • Reduced activity
  • Difficulty waking

Seizures or abnormal movements:

  • Convulsions
  • Jitteriness
  • Hypotonia or hypertonia

Community Health Nurse Actions for Suspected Neonatal Sepsis

Immediate Actions:

  1. Assess vital signs (temperature, respiratory rate, heart rate)
  2. Assess for danger signs using IMNCI guidelines
  3. If sepsis is suspected, arrange for immediate referral
  4. If transportation delay is expected:
    • Give first dose of injectable antibiotics if available and trained
    • Maintain temperature (skin-to-skin contact)
    • Support breastfeeding if possible

Prevention Strategies:

  • Clean delivery practices
  • Hand hygiene before handling newborn
  • Clean cord care
  • Exclusive breastfeeding
  • Prompt recognition and management of maternal infections
  • Avoid unnecessary antibiotic use
  • Early identification and care of high-risk newborns

3.3 Respiratory Distress

Respiratory distress is one of the most common reasons for neonatal emergencies and requires prompt recognition and management. Community health nurses should be skilled in identifying respiratory distress as part of effective newborn care.

Identifying Respiratory Distress – The “RAPID” Assessment

Rate:

  • Normal: 40-60 breaths/minute
  • Tachypnea: >60 breaths/minute
  • Count for full minute when infant is calm

Accessory muscle use:

  • Nasal flaring
  • Chest indrawing (subcostal, intercostal)
  • Sternal retractions

Play of alae nasi:

  • Nostril flaring during inspiration
  • Indicates increased work of breathing
  • Early sign of respiratory distress

Insufficiency (color):

  • Central cyanosis (blue tongue/lips)
  • Pallor
  • Mottled skin

Drawing in (retractions) and grunting:

  • Retractions: Visible sinking of chest wall during inspiration
  • Severity: Mild (subcostal only), Moderate (+ intercostal), Severe (+ sternal/suprasternal)
  • Grunting: Audible sound during expiration
  • Effort to maintain positive end-expiratory pressure and prevent alveolar collapse
  • Significant sign requiring immediate attention

Mnemonic: “BUBBLE” – Causes of Respiratory Distress

  • Blood (anemia, hypovolemia)
  • Upper airway anomalies
  • Bronchiolitis/respiratory infections
  • Block (pneumothorax)
  • Lung problems (RDS, MAS)
  • Edema (heart failure, sepsis)

Community Management of Respiratory Distress

  1. Position the infant with neck slightly extended (sniffing position)
  2. Clear airway if secretions are present (gentle suctioning if available)
  3. Keep warm (skin-to-skin contact)
  4. Monitor vital signs
  5. Arrange immediate referral to higher facility
  6. During transport:
    • Maintain position with slight neck extension
    • Continue skin-to-skin contact for warmth
    • Monitor breathing continuously
    • Consider supplemental oxygen if available and trained

3.4 Hypothermia

Hypothermia in newborns (temperature below 36.5°C) is a common and dangerous condition that can lead to increased metabolic rate, hypoglycemia, metabolic acidosis, and increased mortality. Prevention and management of hypothermia are essential components of newborn care.

Classification of Hypothermia

Category Temperature Range Clinical Significance
Normal 36.5°C – 37.5°C Optimal temperature
Mild hypothermia
(Cold stress)		 36.0°C – 36.4°C Increased metabolic rate and oxygen consumption
Moderate hypothermia 32.0°C – 35.9°C Decreased activity, poor feeding, weak cry
Severe hypothermia < 32.0°C Bradycardia, respiratory depression, acidosis, coagulopathy

Clinical Signs of Hypothermia

Early Signs:

  • Cold extremities (hands and feet)
  • Skin cold to touch (especially abdomen)
  • Reduced activity
  • Poor feeding

Progressive Signs:

  • Lethargy
  • Weak cry
  • Poor sucking reflex
  • Shallow, slow breathing

Severe Signs (Emergency):

  • Edema (especially of legs)
  • Skin bright red (cold injury)
  • Bradycardia
  • Respiratory depression
  • Hypoglycemia

Community-Based Management of Hypothermia

Mild Hypothermia (36.0°C – 36.4°C):

  1. Skin-to-skin contact (Kangaroo Mother Care)
  2. Cover both mother and baby with warm blanket
  3. Cover baby’s head with a cap
  4. Ensure warm environment
  5. Encourage frequent breastfeeding
  6. Monitor temperature every hour until normal

Moderate to Severe Hypothermia:

  1. Immediate skin-to-skin contact
  2. If effective, continue KMC with close monitoring
  3. If ineffective after 1-2 hours or if severe:
    • Arrange urgent referral
    • Continue skin-to-skin during transport
    • Use additional external heat sources if available
  4. Monitor for signs of sepsis (often accompanies hypothermia)

The “Warm Chain” Concept:

A series of interconnected procedures to minimize heat loss from birth onwards:

  1. Warm delivery room (≥25°C)
  2. Immediate drying
  3. Skin-to-skin contact
  4. Early breastfeeding
  5. Postponing bathing for at least 24 hours
  6. Appropriate clothing and bedding
  7. Mother and baby kept together
  8. Warm transportation when required
  9. Training and awareness of healthcare providers
  10. Warm resuscitation (if needed)

3.5 Low Birth Weight

Low birth weight (LBW) is defined as birth weight less than 2500 grams regardless of gestational age. LBW newborns require special newborn care and community health nurses play a critical role in their management and follow-up.

Classifications of Low Birth Weight

  • By Weight:

    • Low Birth Weight (LBW): <2500 grams
    • Very Low Birth Weight (VLBW): <1500 grams
    • Extremely Low Birth Weight (ELBW): <1000 grams

  • By Gestational Age:

    • Preterm: Born before 37 completed weeks
    • Term but Small for Gestational Age (SGA): Below 10th percentile for gestational age
    • Appropriate for Gestational Age (AGA): Between 10th and 90th percentile

Common Problems in LBW Infants

  • Hypothermia
  • Feeding difficulties
  • Respiratory distress
  • Hypoglycemia
  • Jaundice
  • Infections
  • Anemia
  • Developmental delays

Risk Factors for LBW

Maternal:

  • Poor nutrition
  • Young age (<18 years)
  • Multiple pregnancies
  • Chronic illness
  • Substance abuse

Other:

  • Short pregnancy intervals
  • Inadequate prenatal care
  • Placental problems
  • Infections during pregnancy
  • Poverty, low education

Community-Based Management of LBW Infants

Kangaroo Mother Care (KMC)

An evidence-based method involving:

  • Continuous skin-to-skin contact between mother and baby
  • Exclusive breastfeeding
  • Early discharge with close follow-up

Benefits:

  • Maintains temperature
  • Promotes breastfeeding
  • Reduces infection risk
  • Improves weight gain
  • Strengthens mother-baby bonding
  • Decreases mortality and morbidity
Feeding Support
  • Exclusive breastfeeding when possible
  • For babies >1800g with good sucking reflex:
    • Direct breastfeeding
    • 8-12 feeds in 24 hours
  • For babies <1800g or weak sucking:
    • Expressed breast milk by cup/spoon
    • Feed every 2-3 hours
    • Calculate volume needs (starting at 80ml/kg/day, increasing gradually)
  • Signs of adequate feeding:
    • Passing urine 6-8 times/day
    • Weight gain of 15-20g/kg/day
    • Alert and active
Follow-up and Home-Based Care

Home Visit Schedule:

  • First visit within 24-48 hours of discharge
  • Twice weekly until weight ≥2500g
  • Then weekly until 6 weeks of age
  • Then monthly until 3 months corrected age

During Home Visits:

  • Monitor weight gain
  • Check temperature
  • Assess feeding techniques
  • Check for danger signs
  • Ensure KMC is practiced correctly
  • Verify immunization status
  • Provide psychosocial support

4. Management of Common Child Health Problems

Beyond newborn care, community health nurses must be adept at managing common health problems affecting children under five years. Early identification and appropriate management of these conditions significantly reduces childhood mortality and morbidity.

4.1 Pneumonia

Pneumonia remains a leading cause of death in children under five worldwide. Community health nurses play a crucial role in early identification, initial management, and appropriate referral.

Classification of Pneumonia

Classification Signs/Symptoms
Severe Pneumonia
  • Fast breathing plus:
  • Chest indrawing
  • Stridor when calm
  • General danger signs
Pneumonia
  • Fast breathing:
    • ≥60 breaths/min (<2 months)
    • ≥50 breaths/min (2-12 months)
    • ≥40 breaths/min (1-5 years)
  • No chest indrawing
  • No general danger signs
No Pneumonia
(Cough/Cold)
  • No fast breathing
  • No chest indrawing
  • No danger signs

General Danger Signs (Any of These)

  • Unable to drink/breastfeed
  • Vomits everything
  • Convulsions
  • Lethargy/unconsciousness
  • Severe chest indrawing
  • Stridor in a calm child

Management of Pneumonia in Community

Severe Pneumonia:

  1. Give first dose of appropriate antibiotic
  2. URGENT referral to hospital
  3. Keep child warm during transport
  4. If hypoxic and oxygen available, give oxygen

Pneumonia:

  1. Oral antibiotics for 5 days:
    • Amoxicillin 40mg/kg/dose twice daily
    • Alternative: Co-trimoxazole
  2. Home care instructions
  3. Follow-up in 2 days

Home Care Advice for Parents:

  • Complete full course of antibiotics
  • Increase fluids and continue feeding
  • Clear nasal obstruction with saline drops
  • Soothe throat and relieve cough with safe remedies
  • Return immediately if condition worsens or cannot drink
  • Follow-up visit as scheduled

Prevention Strategies for Pneumonia

Immunization:

  • Routine childhood vaccines
  • Pneumococcal vaccine
  • Haemophilus influenzae type b (Hib) vaccine
  • Influenza vaccine
  • Measles vaccine

Nutrition:

  • Exclusive breastfeeding (6 months)
  • Adequate complementary feeding
  • Vitamin A supplementation
  • Zinc supplementation
  • Adequate calories and protein

Environmental:

  • Reduce indoor air pollution
  • Promote handwashing
  • Improve housing conditions
  • Reduce exposure to tobacco smoke
  • Adequate ventilation

4.2 Diarrhea

Diarrhea is defined as the passage of three or more loose or watery stools per day. It remains a leading cause of childhood mortality despite being highly preventable and treatable. Community health nurses provide crucial newborn care and child health services to manage and prevent diarrheal diseases.

Assessment and Classification

1. Duration:

  • Acute diarrhea: <14 days
  • Persistent diarrhea: ≥14 days
  • Chronic diarrhea: >30 days

2. Dehydration Status:

Severe Dehydration
(2 or more signs)		 Some Dehydration
(2 or more signs)		 No Dehydration
  • Lethargy/unconsciousness
  • Sunken eyes
  • Very slow skin pinch (>2 sec)
  • Unable to drink
  • Restlessness, irritability
  • Sunken eyes
  • Slow skin pinch (≤2 sec)
  • Drinks eagerly, thirsty
  • Alert, responsive
  • Eyes normal
  • Skin pinch goes back immediately
  • Drinks normally

3. Dysentery:

  • Blood in stool
  • Typically caused by Shigella, Entamoeba histolytica, or Campylobacter

Management of Diarrhea

Treatment Plan A: No Dehydration

  • Continue breastfeeding
  • Increase fluid intake
  • Give ORS for each loose stool:
    • <2 years: 50-100 ml
    • 2+ years: 100-200 ml
  • Continue age-appropriate feeding
  • Zinc supplementation for 10-14 days
  • Return if condition worsens

Treatment Plan B: Some Dehydration

  • Calculate ORS needed: 75ml/kg over 4 hours
  • Show how to give ORS
  • Reassess after 4 hours and reclassify
  • Start feeding as soon as child can eat
  • Zinc supplementation
  • If child vomits, wait 10 minutes, then continue slower

Treatment Plan C: Severe Dehydration

  • URGENT referral to hospital
  • Give ORS on the way if child can drink
  • If available and trained, start IV fluids

Mnemonic: “WASH-F” for Diarrhea Prevention

W

Water

  • Safe drinking water
  • Water treatment
  • Safe storage

A

Adequate Sanitation

  • Proper toilets
  • Safe disposal of feces
  • Clean environment

S

Sanitation & Hygiene

  • Handwashing with soap
  • Food hygiene
  • Clean utensils

H

Health Education

  • Community education
  • Promotion of ORS
  • Danger signs

F

Food Safety

  • Safe food preparation
  • Breastfeeding
  • Safe complementary feeding

Preparation and Administration of ORS

How to Prepare ORS Solution:
  1. Wash hands with soap and water
  2. Pour the entire contents of one ORS packet into a clean container
  3. Measure 1 liter of clean drinking water
  4. Add the water to the ORS powder and mix until dissolved
  5. Taste the solution (should taste no saltier than tears)
  6. Cover the container and use within 24 hours
How to Give ORS:
  • Use a clean cup or spoon (bottles are difficult to clean)
  • Give small amounts frequently (1-2 teaspoons every 1-2 minutes for an infant)
  • If child vomits, wait 10 minutes then continue more slowly
  • Continue giving ORS until diarrhea stops
  • For infants under 6 months, continue breastfeeding
  • For older children, offer food every 3-4 hours

If ORS packets are not available, a homemade solution can be prepared: 1 liter of clean water + 8 level teaspoons of sugar + 1 level teaspoon of salt (measure precisely)

4.3 Sepsis in Children

Sepsis in children is a life-threatening condition characterized by a dysregulated host response to infection. Early recognition and prompt intervention are crucial for favorable outcomes. Moving beyond newborn care to older children, community health nurses must be vigilant for signs of sepsis.

Recognition of Sepsis – Early Warning Signs

Vital Signs:

  • Temperature >38.5°C or <36°C
  • Tachycardia (heart rate higher than normal for age)
  • Tachypnea (respiratory rate higher than normal for age)
  • Decreased capillary refill (>2 seconds)

Mental Status:

  • Lethargy or decreased responsiveness
  • Irritability
  • Confusion
  • Reduced activity

Other Signs:

  • Reduced urine output
  • Cold extremities
  • Mottled skin
  • Poor feeding/refusal to eat
  • Unusual persistent crying (infants)
  • Convulsions

Common Sources of Infection in Childhood Sepsis

Respiratory:

  • Pneumonia
  • Bronchiolitis
  • Upper respiratory infections

Gastrointestinal:

  • Gastroenteritis
  • Appendicitis
  • Peritonitis

Urinary Tract:

  • Urinary tract infection
  • Pyelonephritis

Skin and Soft Tissue:

  • Cellulitis
  • Infected wounds
  • Abscess

Central Nervous System:

  • Meningitis
  • Encephalitis

Mnemonic: “SEPTIC” – Community Health Nurse Actions for Suspected Sepsis

Screen thoroughly:

  • Check vital signs (temperature, pulse, respiration)
  • Assess for danger signs
  • Check capillary refill and skin color

Evaluate history:

  • Ask about onset and duration of symptoms
  • Previous similar episodes
  • Recent illnesses or infections

Prioritize urgent referral:

  • Arrange immediate transportation
  • Call ahead to hospital if possible
  • Minimize delays in seeking care

Treatment initiation:

  • Give first dose of antibiotics if available and trained
  • Treat fever with antipyretics if >38.5°C
  • Position appropriately during transport

Inform caregivers:

  • Explain seriousness of condition
  • Provide clear instructions
  • Emphasize urgency of hospital care

Continue monitoring:

  • Monitor vital signs during transport
  • Observe for worsening symptoms
  • Document findings and interventions

Prevention of Sepsis in Children

Primary Prevention:

  • Complete immunization schedule
  • Adequate nutrition and breastfeeding
  • Hand hygiene and environmental sanitation
  • Safe water and food handling
  • Early treatment of infections

High-Risk Groups:

  • Children with chronic conditions
  • Immunocompromised children
  • Malnourished children
  • Children with previous sepsis episodes
  • Children with indwelling medical devices
  • Very young infants

Community Education:

  • Recognition of danger signs
  • When to seek immediate care
  • Importance of completing antibiotic courses
  • Avoiding self-medication with antibiotics
  • Wound care and infection prevention

4.4 Malnutrition

Malnutrition remains a significant public health challenge affecting child health globally. Community health nurses play a crucial role in early identification, management, and prevention of malnutrition, extending beyond newborn care through the critical early childhood period.

Assessment and Classification

Anthropometric Measurements:

  • Weight-for-age: Underweight (general indicator)
  • Height/length-for-age: Stunting (chronic malnutrition)
  • Weight-for-height/length: Wasting (acute malnutrition)
  • Mid-Upper Arm Circumference (MUAC): Quick screening tool
    • 6-59 months: <11.5 cm = Severe acute malnutrition
    • 11.5-12.5 cm = Moderate acute malnutrition
    • >12.5 cm = Normal

Clinical Signs of Severe Malnutrition:

Marasmus:

  • Severe wasting
  • “Old man” appearance
  • Visible ribs
  • Loose skin folds
  • No edema

Kwashiorkor:

  • Bilateral pitting edema
  • Skin changes (flaky paint dermatosis)
  • Hair changes (sparse, easily pluckable)
  • Enlarged liver
  • Apathy

Community-Based Management

Moderate Acute Malnutrition (MAM):

  • Supplementary feeding programs
  • Fortified blended foods
  • Micronutrient supplementation
  • Regular growth monitoring
  • Counseling on feeding practices
  • Treatment of concurrent infections

Severe Acute Malnutrition (SAM) without Complications:

  • Community-based therapeutic care using Ready-to-Use Therapeutic Food (RUTF)
  • Weekly follow-up
  • Routine medications:
    • Broad-spectrum antibiotics
    • Vitamin A supplementation
    • Deworming
    • Measles vaccination if needed
  • Discharge when:
    • 15% weight gain maintained
    • MUAC >12.5 cm for two consecutive visits
    • Clinically well and alert

SAM with Complications – REFER IMMEDIATELY:

  • Edema +++ (severe edema)
  • Poor appetite/inability to eat
  • Severe dehydration
  • High fever
  • Lower respiratory tract infection
  • Severe anemia
  • Altered consciousness

Nutritional Rehabilitation and Counseling

Feeding Recommendations by Age:
Age Feeding Recommendations
0-6 months Exclusive breastfeeding on demand (at least 8 times in 24 hours)
6-9 months Continue breastfeeding + introduce complementary foods 2-3 times daily
9-12 months Continue breastfeeding + complementary foods 3-4 times daily
12-24 months Continue breastfeeding + family foods 4-5 times daily
24-59 months Family foods 4-5 times daily with diverse food groups
Key Counseling Messages for Caregivers:
  1. Frequency: Increase meal frequency for malnourished children
  2. Amount: Gradually increase quantity at each meal
  3. Thickness/consistency: Use thick rather than watery foods
  4. Variety: Include foods from multiple food groups daily
  5. Active feeding: Feed with patience, encourage but don’t force
  6. Hygiene: Safe food preparation and handwashing
  7. During illness: Continue feeding during illness and increase after
  8. Responsive feeding: Recognize and respond to hunger cues

Mnemonic: “ABCDEFGHI” for Child Nutrition Success

Adequate complementary foods

Breastfeeding continuation

Calorically dense foods

Diverse food groups

Extra meals during recovery

Frequent feeding

Growth monitoring

Hygiene practices

Illness management

5. Screening for Congenital Anomalies and Referral

Early detection of congenital anomalies is an essential component of comprehensive newborn care. Community health nurses are often the first healthcare providers to identify abnormalities that require specialized intervention.

Common Congenital Anomalies

Cardiovascular System:

  • Ventricular septal defect (VSD)
  • Atrial septal defect (ASD)
  • Patent ductus arteriosus (PDA)
  • Tetralogy of Fallot
  • Coarctation of aorta

Central Nervous System:

  • Neural tube defects (anencephaly, spina bifida)
  • Hydrocephalus
  • Microcephaly

Gastrointestinal System:

  • Cleft lip and/or palate
  • Esophageal atresia
  • Imperforate anus
  • Intestinal malrotation

Musculoskeletal System:

  • Clubfoot (talipes equinovarus)
  • Polydactyly/syndactyly
  • Developmental dysplasia of the hip
  • Osteogenesis imperfecta

Screening Methods in Community Settings

Physical Examination:

  • General appearance: Dysmorphic features, unusual posture
  • Head: Size, shape, fontanelles, sutures
  • Face: Symmetry, cleft lip/palate
  • Eyes: Position, size, red reflex
  • Chest: Shape, breathing pattern
  • Heart: Murmurs, rate, rhythm
  • Abdomen: Enlarged organs, masses
  • Genitalia: Ambiguous genitalia, hypospadias
  • Extremities: Limb abnormalities, digits, joints
  • Spine: Integrity, dimples, tufts of hair
  • Skin: Color, birthmarks, abnormal pigmentation

Simple Screening Tests:

  • Barlow and Ortolani test for hip dysplasia
  • Red reflex testing for eye abnormalities
  • Pulse oximetry for critical congenital heart defects
  • Hearing screening

Mnemonic: “ANOMALY” – Red Flags for Congenital Anomalies

Appearance abnormalities:

  • Dysmorphic facial features
  • Abnormal body proportions
  • Unusual skin coloration or markings

Leave a Reply

Your email address will not be published. Required fields are marked *

Related Posts