Editing Pediatric Nursing

'''Pediatric nursing''' is the care of patients from birth through adolescence. The governing principle of the specialty is that a child is not a miniature adult. Airway diameter, cardiac reserve, body surface area, renal clearance, glycogen stores, and cognitive capacity all differ from adult values, and every one of those differences changes how illness presents and how the nurse intervenes. This article covers the core content tested on both the NCLEX-RN and the NCLEX-PN.

== Age groupings used in pediatrics ==

Pediatric norms are always reported by age band, and the exam expects the bands to be known.

* '''Neonate:''' birth to 28 days
* '''Infant:''' 1 month to 12 months
* '''Toddler:''' 1 to 3 years
* '''Preschooler:''' 3 to 6 years
* '''School-age child:''' 6 to 12 years
* '''Adolescent:''' 12 to 18 years

'''Application note.''' When a question gives an age, immediately translate it into the band before reading the options. Most pediatric items are answerable once the correct developmental stage is identified, because the safe answer for a toddler is frequently the wrong answer for a school-age child.

== Physical growth parameters ==

=== Weight ===

* Newborns lose up to 10 percent of birth weight in the first few days of life and regain it by about 2 weeks of age. Loss beyond 10 percent, or failure to regain by 2 weeks, requires evaluation.
* Birth weight '''doubles by about 4 to 6 months''' and '''triples by 12 months'''.
* Weight roughly quadruples by 2 to 2.5 years.
* After the toddler years, children gain approximately 2 to 3 kg per year until the pubertal growth spurt.

=== Length and height ===

* Birth length increases by about 50 percent by 12 months.
* Height roughly doubles by 4 years of age.
* Length is measured recumbent until age 2 or 3; after that, standing height is measured.

=== Head circumference and fontanels ===

* Head circumference is measured at the widest point, just above the eyebrows and over the occipital prominence, and is routinely tracked through 36 months.
* Head circumference '''exceeds chest circumference until about 12 months''', at which point they are approximately equal; after that, chest circumference exceeds head circumference.
* The '''posterior fontanel closes at 2 to 3 months'''.
* The '''anterior fontanel closes at 12 to 18 months'''.

'''Application note.''' A '''bulging, tense fontanel''' in a quiet infant suggests increased intracranial pressure and is an urgent finding. A '''sunken fontanel''' suggests dehydration. Transient bulging with crying, coughing, or vomiting is normal. A fontanel that has not closed by 18 months, or a head circumference crossing percentile lines upward, warrants referral for possible hydrocephalus.

=== Dentition ===

* First primary teeth typically erupt at 6 to 8 months, beginning with the lower central incisors.
* A rough estimate for the number of primary teeth in the first two years is age in months minus 6.
* All 20 primary teeth are usually present by 30 months.
* The first dental visit is recommended by 12 months or within 6 months of the first tooth.

== Developmental milestones by age ==

Milestones are the single highest-yield pediatric topic. The following are the classic teaching benchmarks. Note that the United States Centers for Disease Control and Prevention revised its public milestone checklists in 2022 to reflect the age by which about 75 percent of children achieve a skill, which shifted a few published ages later than the traditional 50th-percentile figures (Zubler et al., 2022). Licensure examinations continue to test the traditional benchmarks below.

=== Infant (birth to 12 months) ===

* '''1 month:''' lifts head briefly when prone; fists mostly clenched; responds to sound.
* '''2 months:''' '''social smile'''; follows objects past midline; coos.
* '''3 months:''' holds head steady; hands open more of the time.
* '''4 months:''' '''rolls front to back'''; brings hands to midline; laughs; head lag disappears when pulled to sit.
* '''5 to 6 months:''' rolls both directions; sits with support progressing to tripod sitting; '''transfers objects hand to hand'''; begins babbling; '''stranger anxiety begins'''; birth weight doubles.
* '''7 to 8 months:''' sits unsupported; bears weight on legs; raking grasp.
* '''9 months:''' crawls; pulls to stand; '''crude pincer grasp'''; understands "no"; '''object permanence''' is established.
* '''10 to 11 months:''' cruises along furniture; neat pincer grasp; waves bye-bye.
* '''12 months:''' walks with one hand held or takes first independent steps; says 1 to 3 meaningful words plus "mama" and "dada"; triples birth weight; can drink from a cup.

=== Toddler (1 to 3 years) ===

* '''15 months:''' walks independently; builds a 2-cube tower; uses a spoon with spilling; 4 to 6 words.
* '''18 months:''' runs stiffly; climbs stairs with help; builds a 3- to 4-cube tower; 10 to 20 words; points to body parts; '''temper tantrums and negativism''' emerge.
* '''24 months:''' walks up and down stairs one step at a time; kicks a ball; builds a 6- to 7-cube tower; '''two-word phrases'''; roughly 300 words; speech about 50 percent intelligible to strangers; turns pages one at a time; begins '''parallel play'''.
* '''30 months:''' jumps with both feet; builds an 8-cube tower; copies a vertical line; knows first and last name; daytime toilet training often achieved.
* '''36 months:''' '''rides a tricycle'''; '''copies a circle'''; builds a 9- to 10-cube tower; 3-word sentences; speech about 75 percent intelligible.

=== Preschooler (3 to 6 years) ===

* '''4 years:''' '''hops on one foot'''; throws overhand; '''copies a cross and a square'''; draws a person with 3 parts; uses 4- to 5-word sentences; speech fully intelligible; engages in '''associative play''' and magical thinking.
* '''5 years:''' '''skips'''; '''copies a triangle'''; ties shoelaces; prints some letters and own name; draws a person with 6 parts; counts to 10; names 4 colors.

=== School-age (6 to 12 years) ===

* Fine motor control refines enough for cursive writing and musical instruments.
* Concrete logical thinking develops; the child can classify, sequence, and understand cause and effect.
* Peer groups and same-sex friendships dominate; rules and fairness matter intensely.
* '''Cooperative play''' with organized games and teams.
* Loss of primary teeth begins around age 6.

=== Adolescent (12 to 18 years) ===

* Puberty typically begins at '''8 to 13 years in girls''' (first sign: '''thelarche''', breast budding) and '''9 to 14 years in boys''' (first sign: '''testicular enlargement''').
* '''Menarche''' occurs on average about 2 to 2.5 years after thelarche, near the peak of the growth spurt.
* Abstract reasoning develops, but risk assessment lags behind, which explains the high rate of injury deaths in this group.
* Identity formation, peer conformity, and the personal fable ("it will not happen to me") shape health behavior.

=== Theoretical frameworks ===

{| class="wikitable"
! Age band !! Erikson (psychosocial) !! Piaget (cognitive) !! Predominant play
|-
| Infant || Trust vs. mistrust || Sensorimotor || Solitary
|-
| Toddler || Autonomy vs. shame and doubt || Sensorimotor into preoperational || Parallel
|-
| Preschooler || Initiative vs. guilt || Preoperational || Associative
|-
| School-age || Industry vs. inferiority || Concrete operational || Cooperative
|-
| Adolescent || Identity vs. role confusion || Formal operational || Peer group activity
|}

'''Application note.''' Nursing interventions map directly onto these stages. For a hospitalized toddler, support '''autonomy''' by offering limited choices ("apple juice or water?") and maintaining home rituals. For a preschooler, address '''magical thinking''' and the belief that illness is punishment; correct the fantasy that a procedure is a consequence of misbehavior. For a school-age child, support '''industry''' by allowing participation in care and keeping up with schoolwork. For an adolescent, protect '''privacy and body image''' and allow peer contact.

== Pediatric vital sign norms ==

Values vary slightly by source. The ranges below are consistent with Pediatric Advanced Life Support reference tables (American Heart Association, 2020).

{| class="wikitable"
! Age !! Heart rate (awake, beats/min) !! Respiratory rate (breaths/min) !! Systolic BP (mmHg)
|-
| Newborn || 100 to 205 || 30 to 60 || 67 to 84
|-
| Infant (1 to 12 mo) || 100 to 180 || 30 to 53 || 72 to 104
|-
| Toddler (1 to 2 yr) || 98 to 140 || 22 to 37 || 86 to 106
|-
| Preschool (3 to 5 yr) || 80 to 120 || 20 to 28 || 89 to 112
|-
| School-age (6 to 11 yr) || 75 to 118 || 18 to 25 || 97 to 115
|-
| Adolescent (12 to 15 yr) || 60 to 100 || 12 to 20 || 110 to 131
|}

=== Defining hypotension ===

Hypotension in children is a '''late''' sign. The commonly taught thresholds for systolic blood pressure are:

* Neonate (0 to 28 days): less than 60 mmHg
* Infant (1 to 12 months): less than 70 mmHg
* Child 1 to 10 years: less than 70 + (2 x age in years) mmHg
* Child older than 10 years: less than 90 mmHg

'''Application note.''' This is the most clinically important concept in pediatric assessment. Children compensate for hypovolemia and sepsis with '''tachycardia and vasoconstriction''', maintaining a normal blood pressure until they have lost a large fraction of circulating volume. By the time the blood pressure falls, cardiac arrest may be minutes away. Do not wait for hypotension. The early warning signs are '''tachycardia, tachypnea, delayed capillary refill greater than 2 to 3 seconds, cool and mottled extremities, weak peripheral pulses compared with central pulses, decreased urine output, and altered level of consciousness'''. A previously irritable child who becomes '''lethargic and quiet''' is deteriorating, not improving.

=== Other measurement points ===

* Count '''respirations for a full minute''' in infants and young children, since breathing is irregular. Count them before disturbing the child.
* Take the '''apical pulse for a full minute''' in children under 2 years.
* Blood pressure cuff bladder width should cover about 40 percent of the arm circumference and the bladder should encircle 80 to 100 percent of the arm. A '''cuff that is too small falsely elevates''' the reading.
* '''Urine output''' expectations: infants 2 mL/kg/hr, children 1 to 2 mL/kg/hr, adolescents 0.5 to 1 mL/kg/hr. Infant output is measured by weighing diapers, where 1 gram of weight gain equals 1 mL of urine.
* Fever in an infant '''younger than 28 days''' with a rectal temperature of 38.0 degrees Celsius (100.4 degrees Fahrenheit) or higher is a medical emergency requiring a full sepsis workup, because young infants can be bacteremic without any localizing signs.

== Respiratory considerations ==

Respiratory failure is the most common pathway to cardiac arrest in children, so pediatric arrests are usually '''asphyxial''' rather than the sudden ventricular arrhythmias seen in adults. Anatomic reasons include:

* A proportionally large tongue and occiput, and a narrow, funnel-shaped airway. A small amount of edema markedly reduces the airway lumen because resistance rises steeply as radius falls.
* Short, horizontally oriented eustachian tubes, which predispose to otitis media.
* Fewer alveoli and less elastic recoil, so less respiratory reserve.
* Highly compliant chest wall, which produces '''retractions''' rather than effective ventilation when effort increases.
* Infants younger than about 4 to 6 months are largely obligate nose breathers, so nasal congestion alone can cause distress and feeding failure.
* Higher metabolic rate and oxygen consumption, so desaturation occurs quickly.

'''Signs of respiratory distress and impending failure.''' Nasal flaring, grunting, retractions (subcostal to intercostal to supraclavicular as severity increases), head bobbing, tachypnea, and stridor indicate distress. '''Bradycardia, a silent chest, decreased responsiveness, and a slowing respiratory rate in a child who was previously tachypneic are signs of impending arrest''', not improvement.

== Common childhood illnesses ==

=== Otitis media ===

Presents with ear pain, ear tugging in preverbal children, fever, irritability, and a bulging, erythematous, immobile tympanic membrane. Feeding an infant '''flat on the back with a propped bottle''' and exposure to tobacco smoke are modifiable risk factors. Many cases are managed with observation and analgesia; antibiotics are prescribed for younger infants, severe symptoms, or bilateral disease. Teach caregivers to complete the entire antibiotic course. After myringotomy with tympanostomy tube placement, teach that '''drainage for a few days is expected''' and that tubes usually extrude spontaneously in 6 to 12 months.

=== Croup (laryngotracheobronchitis) ===

Viral, usually in children 6 months to 3 years, gradual onset, often worse at night. Findings are a '''barking or seal-like cough, inspiratory stridor, and hoarseness''' with low-grade fever. Radiography, if obtained, shows the '''steeple sign'''. Management is '''corticosteroids (dexamethasone)''' for nearly all cases and '''nebulized epinephrine''' for stridor at rest, with humidified air and hydration. Keep the child calm, because crying worsens obstruction. Home advice includes cool night air or a cool-mist humidifier.

=== Epiglottitis ===

A true airway emergency, now uncommon because of '''Haemophilus influenzae'''  type b vaccination. Onset is abrupt with high fever and a toxic appearance. Remember the '''four Ds: drooling, dysphagia, dysphonia, and distress''', plus the '''tripod position''' with the chin thrust forward, absence of a cough, and muffled voice.

'''Application note.''' '''Do not inspect the throat, do not obtain a throat culture, and do not place anything in the mouth''', including a tongue blade, because laryngospasm and complete obstruction can result. Keep the child upright in the caregiver's lap, keep the child calm, give nothing by mouth, administer oxygen if tolerated, and notify the provider immediately while emergency airway equipment and personnel are assembled.

=== Bronchiolitis and respiratory syncytial virus ===

Most common in infants under 2 years. Begins with rhinorrhea and progresses to wheezing, tachypnea, retractions, and poor feeding. '''Apnea may be the presenting sign in young infants and in former preterm infants.''' Management is supportive: nasal suctioning before feeds, hydration, oxygen, and monitoring. '''Contact plus droplet precautions''' are required. Palivizumab or an equivalent monoclonal antibody may be given as prophylaxis to high-risk infants; it is prophylaxis, not treatment.

=== Asthma ===

Chronic airway inflammation with reversible obstruction. Teach the distinction between '''rescue''' medication (short-acting beta-2 agonist such as albuterol) and '''controller''' medication (inhaled corticosteroid taken daily even when well). Teach spacer use with a mask for younger children, rinsing the mouth after inhaled corticosteroids to prevent oral candidiasis, and peak flow zones (green 80 to 100 percent of personal best, yellow 50 to 79 percent, red below 50 percent). A '''quiet chest with absent wheezing in a child in distress signals severe obstruction and is worse, not better'''.

=== Gastroenteritis and dehydration ===

Dehydration is graded by weight loss and clinical signs. Early findings include decreased urine output, dry mucous membranes, and absence of tears. Later findings are sunken eyes and fontanel, poor skin turgor, tachycardia, and lethargy. '''Weight change is the most accurate measure of fluid loss in children.'''

* '''Oral rehydration solution is first-line for mild to moderate dehydration''', given in small frequent volumes. Plain water, juice, soda, and sports drinks are inappropriate because of inadequate or unbalanced electrolyte content.
* Severe dehydration or shock is treated with a '''20 mL/kg bolus of isotonic crystalloid''' (0.9 percent sodium chloride or lactated Ringer's), which may be repeated with reassessment after each bolus.
* Rotavirus vaccine has substantially reduced severe infantile gastroenteritis.
* Contact precautions apply; alcohol-based hand rub is not reliable against norovirus or ''Clostridioides difficile'', so use soap and water.

=== Pyloric stenosis ===

Typically presents at '''3 to 6 weeks of age''' with '''projectile, non-bilious vomiting''' immediately after feeding, in an infant who is '''hungry again right afterward'''. A firm, olive-shaped mass may be palpable in the right upper quadrant, and visible peristaltic waves may cross the abdomen. Loss of gastric contents produces '''hypochloremic, hypokalemic metabolic alkalosis'''. Treatment is pyloromyotomy after fluid and electrolyte correction.

=== Intussusception ===

Telescoping of bowel, most often between 3 months and 3 years. Sudden, severe, '''colicky abdominal pain with the knees drawn to the chest''', alternating with pain-free intervals; vomiting; a '''sausage-shaped right-sided abdominal mass'''; and the late finding of '''"currant jelly" stools''' containing blood and mucus. Treated with air or hydrostatic contrast enema, with surgery if that fails. '''The passage of a normal brown stool may indicate spontaneous reduction and must be reported immediately, because it changes the plan of care.'''

=== Kawasaki disease ===

An acute vasculitis of young children. Classic criteria are '''fever lasting 5 or more days''' plus at least four of: '''bilateral non-exudative conjunctivitis; oral changes including strawberry tongue and cracked lips; polymorphous rash; extremity changes with erythema and edema of the hands and feet followed by periungual peeling; and unilateral cervical lymphadenopathy'''. The child is characteristically extremely irritable.

'''Application note.''' The danger is '''coronary artery aneurysm'''. Treatment is '''intravenous immunoglobulin plus aspirin''', and echocardiography is obtained at baseline and in follow-up. Kawasaki disease is one of the few pediatric indications for aspirin. Because IVIG contains live-virus antibodies, '''live vaccines such as measles-mumps-rubella and varicella must be deferred for about 11 months''' after high-dose IVIG.

=== Febrile seizures ===

Usually occur between 6 months and 5 years with a rapid rise in temperature. Simple febrile seizures are generalized, last under 15 minutes, and do not recur within 24 hours. Nursing care is protective: '''turn the child to the side, do not restrain, do not put anything in the mouth''', protect the head, note the time and characteristics, and stay with the child. Antipyretics treat comfort; they have not been shown to prevent recurrence.

=== Bacterial meningitis ===

Findings include fever, headache, photophobia, nuchal rigidity, and altered consciousness. In infants the presentation is nonspecific: poor feeding, high-pitched cry, irritability that worsens when held, a '''bulging fontanel''', and hypothermia or fever. '''Droplet precautions are initiated on suspicion and continued for 24 hours after effective antibiotic therapy begins.''' Position the child with the head of the bed slightly elevated, keep the room quiet and dim, and monitor for increased intracranial pressure and for seizures.

=== Other frequently tested conditions ===

* '''Sickle cell disease:''' vaso-occlusive crisis is managed with hydration, oxygen, warmth, and scheduled analgesia including opioids. '''Cold, dehydration, infection, stress, and high altitude precipitate crises.''' Never apply cold to a painful area. Splenic sequestration presents with a rapidly enlarging spleen and shock and is an emergency.
* '''Cystic fibrosis:''' thick secretions affect lungs, pancreas, and reproductive tract. Findings include meconium ileus in the newborn, steatorrhea, failure to thrive despite a large appetite, and a positive '''sweat chloride''' test. Give '''pancreatic enzymes with every meal and snack''', a high-calorie, high-protein diet, and airway clearance therapy.
* '''Type 1 diabetes mellitus:''' teach carbohydrate counting, rotation of injection sites, sick-day rules, and hypoglycemia treatment with 15 grams of fast-acting carbohydrate. Adolescents may omit insulin for weight control or peer reasons; assess for this.
* '''Nephrotic syndrome''' presents with '''massive proteinuria, hypoalbuminemia, and generalized edema with periorbital swelling worst in the morning'''; corticosteroids are the mainstay. '''Acute post-streptococcal glomerulonephritis''' presents 1 to 3 weeks after a streptococcal infection with '''tea-colored or smoky urine, hypertension, mild edema, and only modest proteinuria'''.
* '''Reye syndrome:''' acute encephalopathy with fatty liver change linked to salicylate use during viral illness. Therefore '''aspirin is avoided in children with viral illness such as influenza or varicella''' unless specifically indicated as in Kawasaki disease.
* '''Congenital heart disease:''' signs of heart failure in infants include '''poor feeding, diaphoresis while feeding, tachypnea, tachycardia, and poor weight gain'''. In tetralogy of Fallot, a hypercyanotic "tet" spell is managed by placing the infant in the '''knee-chest position''' and giving oxygen while calming the child.

== Medication administration and weight-based dosing ==

Children receive doses individualized to '''body weight in kilograms''' or, for chemotherapy and some other agents, '''body surface area in square meters'''. Immature hepatic enzymes and reduced glomerular filtration in neonates prolong drug half-life; body water percentage is higher, which changes the volume of distribution of water-soluble drugs.

=== The safe dose calculation ===

The nurse's independent responsibility is to '''verify that the ordered dose falls within the safe range before administering it'''.

# Convert the weight to kilograms. '''Divide pounds by 2.2.''' Never estimate; obtain an actual measured weight, and document it in kilograms only, to prevent pound-kilogram mix-ups.
# Multiply the weight in kilograms by the reference safe dose range, noting whether the reference is stated '''per dose''' or '''per day in divided doses'''. Confusing these two is a common and serious error.
# Compare the calculated safe range with the ordered dose.
# If the order falls outside the safe range, '''hold the medication and contact the prescriber'''. Do not adjust a dose independently and do not simply administer it.
# Remember that a pediatric calculated dose should not exceed the usual adult dose.

'''Worked example.''' A child weighs 44 lb. The order reads amoxicillin 45 mg/kg/day by mouth divided every 12 hours; the suspension is 250 mg per 5 mL. 44 divided by 2.2 equals 20 kg. 20 x 45 equals 900 mg per day. Divided every 12 hours equals two doses, so 450 mg per dose. 450 divided by 250 equals 1.8; 1.8 x 5 mL equals '''9 mL per dose'''.

=== Common reference doses ===

* '''Acetaminophen:''' 10 to 15 mg/kg per dose every 4 to 6 hours, not more than 5 doses in 24 hours.
* '''Ibuprofen:''' 5 to 10 mg/kg per dose every 6 to 8 hours; '''not given to infants under 6 months''' without specific direction, and avoided in dehydration because of renal risk.
* '''Maintenance intravenous fluid (Holliday-Segar method):''' 100 mL/kg/day for the first 10 kg, plus 50 mL/kg/day for the second 10 kg, plus 20 mL/kg/day for each kilogram above 20.
* '''Fluid resuscitation bolus:''' 20 mL/kg of isotonic crystalloid.
* '''Digoxin:''' take an '''apical pulse for one full minute''' and hold the dose and notify the provider if the rate is below approximately '''90 to 110 in an infant, 70 in a child, or 60 in an adolescent'''. Early toxicity in children usually appears as '''bradycardia, vomiting, and anorexia'''. Do not repeat a dose that the child vomits.

=== Administration safety practices ===

* Use an '''oral syringe''' calibrated in milliliters. Household teaspoons are inaccurate and must never be used. Direct liquid toward the side of the mouth, slowly, to prevent aspiration.
* Use a leading zero (0.5 mg) and never a trailing zero (5.0 mg), which invites tenfold overdose.
* Perform an '''independent double check by two nurses''' for high-alert medications including insulin, opioids, heparin, chemotherapy, and any intravenous infusion in a neonate.
* Intramuscular site selection: the '''vastus lateralis''' is preferred for infants and young toddlers. The '''deltoid''' can be used in older children with adequate muscle mass. The dorsogluteal site is not used in children because of sciatic nerve risk.
* Never mix medication into a full bottle of formula or an essential food, because refusal or incomplete intake produces an unknown dose and can create food aversion.
* Do not describe medicine as candy.
* Volume-control infusion sets or syringe pumps are used for intravenous medications so that a child cannot receive an inadvertent fluid overload.

== Family-centered and atraumatic care ==

'''Family-centered care''' treats the family as the constant in the child's life and the caregiver as a partner rather than a visitor. Practically this means encouraging caregiver presence, incorporating home routines, sharing information openly, and negotiating which cares the caregiver wishes to perform.

'''Atraumatic care''' means minimizing physical and psychological distress. Examples include using topical anesthetic before venipuncture, clustering blood draws, performing painful procedures in a '''treatment room rather than in the child's bed''' so the bed remains a safe place, allowing a comfort object, and offering distraction.

=== Separation anxiety ===

Most intense in children from about 6 months through 3 years. The classic stages are:

# '''Protest:''' crying, screaming, clinging, rejecting strangers.
# '''Despair:''' withdrawal, sadness, decreased activity, disinterest in play.
# '''Detachment (denial):''' superficial cheerfulness and apparent adjustment.

'''Application note.''' Detachment is frequently misread as a good sign. A toddler who has stopped protesting and now interacts pleasantly with any staff member may have '''given up on the caregiver's return''', and the nursing priority is to restore caregiver contact.

=== Preparing children for procedures ===

{| class="wikitable"
! Age !! Timing of preparation !! Key approach
|-
| Infant || Immediately before || Caregiver presence, swaddling, pacifier, sucrose, minimize restraint
|-
| Toddler || Just before, a few minutes || Simple concrete words, offer limited choices, allow a comfort object, expect resistance
|-
| Preschooler || Shortly before, up to about an hour || Play with equipment, correct magical thinking, state clearly that the procedure is not punishment, use bandages
|-
| School-age || A few days before || Explain purpose and body function, use diagrams and models, allow a job to do, give privacy
|-
| Adolescent || Several days in advance || Full explanation of rationale and outcomes, respect privacy and body image, allow autonomy and peer contact
|}

=== Pain assessment ===

* '''Neonates and preverbal infants:''' behavioral scales such as NIPS or FLACC (face, legs, activity, cry, consolability).
* '''Roughly 3 to 7 years:''' FACES self-report scale.
* '''About 7 years and older:''' numeric 0 to 10 rating scale.
* '''Nonverbal children with cognitive impairment:''' revised FLACC with caregiver input about individual pain behaviors.

Pain is under-treated in children. Absence of crying does not mean absence of pain; a child in severe pain may lie still to avoid making it worse.

=== Consent and communication ===

* Consent is provided by the parent or legal guardian. The child's '''assent''' should be sought when developmentally appropriate.
* '''Emancipated minors''', and in many jurisdictions minors seeking care related to sexually transmitted infections, pregnancy, contraception, or substance use, may consent for themselves. State law varies.
* '''Emergency treatment necessary to preserve life or limb is not withheld while awaiting consent.'''
* Interview adolescents alone for part of the visit to allow confidential disclosure, while explaining the limits of confidentiality.
* Nurses are '''mandated reporters''' of suspected abuse or neglect. Suspicious findings include injuries inconsistent with the reported mechanism or the child's developmental stage, injuries in various stages of healing, delay in seeking care, patterned burns such as symmetric stocking or glove immersion burns, and posterior rib fractures. '''Report suspicion; proof is not required.''' Document objectively using direct quotations rather than conclusions.

== Safety and injury prevention ==

Unintentional injury is the leading cause of death for children beyond infancy, and the specific hazards track directly with developmental capability. Anticipatory guidance means teaching about the next stage, not the current one.

=== Infants ===

* '''Supine sleep on a firm surface''' in a crib with no pillows, bumpers, blankets, or soft toys; room-sharing without bed-sharing.
* Crib slats no more than 2 and three-eighths inches apart; mattress fitted tightly.
* '''Never leave an infant unattended on any elevated surface''', and keep one hand on the infant during a diaper change.
* '''No honey before 12 months''' (infant botulism). '''No whole cow's milk before 12 months.'''
* Introduce single-ingredient complementary foods around 6 months, one at a time for several days.
* '''Infant walkers are not recommended''' and are associated with stair falls and burns.
* Test bath and formula temperature; set the water heater to no higher than 120 degrees Fahrenheit (49 degrees Celsius). Never microwave formula or breast milk.
* Aspiration is the leading injury risk; keep small objects, latex balloons, and coins out of reach.

=== Toddlers and preschoolers ===

* '''Drowning''' is a leading cause of death in the 1 to 4 year age group. Provide touch supervision, four-sided isolation pool fencing with self-latching gates, and empty buckets and tubs immediately.
* '''Choking foods''' to avoid: whole grapes, hot dog rounds, nuts, popcorn, hard candy, raw carrots, chunks of peanut butter. Cut round foods lengthwise.
* '''Poisoning:''' store medications and chemicals locked and out of sight, keep products in original containers, and post the United States national Poison Help line, 1-800-222-1222. Do not induce vomiting and do not give syrup of ipecac.
* Turn pot handles inward; keep hot liquids and appliance cords out of reach.
* Use stair gates, window guards, and cabinet and outlet safety devices.

=== School-age children and adolescents ===

* '''Helmets''' for cycling, skating, and skiing; protective gear for sport.
* Swimming instruction and water safety rules; supervision at all ages.
* Pedestrian, bus, and bicycle traffic safety education.
* '''Firearms stored unloaded and locked, with ammunition locked separately.'''
* Adolescents: motor vehicle safety, seat belt use in every seat, no texting or impairment while driving, substance use, sexual health, social media and bullying, and screening for depression and suicidal ideation. '''Any expression of suicidal ideation is assessed directly and immediately and requires continuous observation and referral.'''

=== Car seat guidance ===

* '''Rear-facing''' car safety seat in the '''back seat''' from birth for as long as possible, at minimum until age 2 and ideally until the child reaches the highest weight or height allowed by the seat manufacturer (Durbin & Hoffman, 2018).
* Then a '''forward-facing seat with a harness''' until the seat's limits are exceeded.
* Then a '''belt-positioning booster''' until the vehicle lap and shoulder belt fits properly, usually at a height near 4 feet 9 inches and between 8 and 12 years of age.
* '''All children younger than 13 ride in the back seat.'''
* A rear-facing seat is never placed in front of an active passenger air bag.
* Harness straps should be '''at or below the shoulders when rear-facing''' and '''at or above the shoulders when forward-facing'''; the retainer clip sits at armpit level, and bulky coats are removed before buckling.

== Immunization principles ==

* Follow the current national schedule; the nurse verifies the schedule rather than working from memory.
* '''Live vaccines''' include measles-mumps-rubella, varicella, live attenuated influenza, and rotavirus. They are generally deferred in significant immunosuppression and in pregnancy, and MMR and varicella given on different days must be separated by at least 4 weeks.
* '''Mild illness with or without low-grade fever is not a contraindication''' to immunization; moderate to severe acute illness is a reason to defer.
* A '''previous anaphylactic reaction''' to a vaccine or one of its components is a true contraindication.
* Teach caregivers to expect low-grade fever and local soreness, to use acetaminophen if needed, and never to give aspirin.
* Document lot number, site, route, date, and provision of the Vaccine Information Statement.

== High-yield nursing priorities summary ==

* Airway and breathing come first; most pediatric arrests begin as respiratory failure.
* '''Hypotension is a late sign of shock.''' Act on tachycardia, delayed capillary refill, mottling, and decreasing level of consciousness.
* Never inspect the throat in suspected epiglottitis.
* Weigh in kilograms, calculate the safe range, and hold and clarify any dose outside it.
* Match the intervention to the developmental stage.
* Keep the caregiver present whenever possible; the caregiver is a therapeutic intervention, not a visitor.
* Report suspected maltreatment; suspicion is sufficient.

== References ==

American Heart Association. (2020). ''Pediatric advanced life support provider manual''. American Heart Association.

Durbin, D. R., & Hoffman, B. D. (2018). Child passenger safety. ''Pediatrics, 142''(5), Article e20182460. https://doi.org/10.1542/peds.2018-2460

Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2022). ''Wong's essentials of pediatric nursing'' (11th ed.). Elsevier.

Moon, R. Y., Carlin, R. F., & Hand, I. (2022). Sleep-related infant deaths: Updated 2022 recommendations for reducing infant deaths in the sleep environment. ''Pediatrics, 150''(1), Article e2022057990. https://doi.org/10.1542/peds.2022-057990

Zubler, J. M., Wiggins, L. D., Macias, M. M., Whitaker, T. M., Shaw, J. S., Squires, S. K., Pajek, J. A., Wolf, R. B., Slaughter, K. S., Broughton, A. S., Gerndt, K. L., Mlodzik, B. J., & Lipkin, P. H. (2022). Evidence-informed milestones for developmental surveillance tools. ''Pediatrics, 149''(3), Article e2021052138. https://doi.org/10.1542/peds.2021-052138

[[Category:Pediatric Nursing]]
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