RND20604

COMMUNITY HEALTH NURSING

CHILD HEALTH CARE

Children is the future of A country
 Learning Outcomes
At the end of this session, the students should be able to:
• define child health care;
• state the objectives of child health care;
• list the stages and scopes of child health care;
• describe child health clinic activities;
• define the growth and development of the child;
• explain the principle of growth and development;
• Identify the factors influencing growth and development;
• explain the assessment of physical growth: anthropometry;
• interpret the child growth chart;
 Learning Outcomes
• identify possible causes of growth deviation in children;
• state the purposes of assessment in child development;
• describe the development milestones of child ( 0 – 6
years old).
• outline the steps in carrying out child health
assessment in clinic.
 Definition of Child Health Care
 Child health care is health supervision and full
medical care, provided by the same group of health
care providers with continuity over a period of time,
to all children from conception, birth till preschool
(Chen, 1989).
 Care and treatment for children.
 Objectives of
Child Health Care (WHO)

To ensure that all children:

 live and grow in a family unit with adequate love, and
a healthy and safe environment;
 receive adequate nutrition;
 receive health monitoring and provision of efficient,
adequate medical services;
 nurtured with all the important elements that are
required to live a long and healthy life.
 Objectives of
Child Health Care (MOH)
 Promoting and maintaining optimum health of children.
 Provide specific protection from communicable diseases
and prevent infections.
 Assess the pattern of growth and development of
children and give health education and counselling
when necessary.
 Early detection of deformities and abnormalities and
refer for prompt treatment.
 Ensure happiness and safety of children is maintained.
 Reduce mortality and morbidity among children.
 Stages of Child Health Care

 Antenatal
 Neonatal
• Early neonatal (1 week)
• Late neonatal (7-28 days)
 Infant: Below one year
 Toddler:1-3 years
 Preschool - Kindergarten
 School: 7 years above till Form 3 in secondary school
 Scope of Child Health Services
 Care of newborn baby
 Child health clinic for children under 6 years
 School health programme for all school children
including kindergarten and form 3
 Dental services
 Immunization programme
 Home visit
 Nutritional assessment and programme
 Prevention of diseases and treatment
 Rehabilitation
 Activities in the
Child Health Clinic
1. Registration 3. Assessment on
• Interview (history-taking) development
• Child well-being
• Nutritional status
2. Anthropometry measurement 4. Routine physical
9. Follow-up care • Weight examination: general
0–6 months : Monthly • Height examination, head to toe
6, 9, 12 months: Three monthly • Head circumference
1–2 years : Three monthly • Chest circumference
2–4 years : Six monthly
5–6 years : Yearly 5. Health education
Child Health and advice
• Nutrition
8. Treatments Clinic Activities • Home safety
• Treatment for minor ailments • Personal hygiene
• Management for malnutrition • Treatment of
child 6. Refer medical officer minor ailment
• Give supplementary vitamin for routine examination • Delay milestone
or refer for abnormality
7. Immunisation
GROWTH AND DEVELOPMENT
Definition of Growth and Development of the
Child (0–6 Years)
Definition of Growth
 A process of changes/and increase in physical size over
time.
 Quantitative changes in size such as height,
circumference of head, chest and arm.
 The changes also involve structure of internal organs
and brain.
 Growth can be measured and assessed via weight,
height, circumference of head and chest.
 Size can change due to individual behaviors OR may
reflect underlying maturational process.
Definition of Growth and Development of the
Child (0–6 Years)
Definition of Development
 Process of growth and change in capability over time
as a function of both maturation and interaction with
environment.
 It involves the acquisition of motor and cognitive skills
during childhood.
 Examples of developmental functions: reading,
walking and learning capacity of the child becomes
better and mental growth is observed.
 Principles of
Growth and Development
1. Cephalocaudle  Develops from head downwards
principle  Begins with crawl, sit, stand and walk
2. Proximodistal  Proceeds from the centre of the body
principle outwards
 Develops from spinal cord and proceeds to
outer part of the body
 The sequence of development is from arms to
hands and legs, followed by fingers and toes
3. Depends on  Maturation depends on the biological growth
maturation and and changes of brain and nervous system
learning  It follows a sequential order and gives children
new abilities to improve cognitive and motor
skills
 Children need to be matured at certain level of
thinking in order to learn new experiences
 Principles of
Growth and Development

Cephalocaudle & A. Cephalocaudle B. proximodistal

proximodistal principle
 Principles of
Growth and Development
4. Proceeds  Child uses cognitive and language skills to solve
from the
simple problems and reasoning
(concrete) to  It begins with ability to classify objects in simple
the more
complex manner to more complex description
 For instance, simple description: tiger and cat are the
same; concrete description: both are different in size
5. Growth and  Ongoing process
development
is a  Add new skills to the old skills that child had acquired
continuous as he/she develops
process
 New skills serve as foundation for future achievement
 Pattern of growth can be predictable
 Principles of
Growth and Development
6. Growth and development  Motor development begins with
proceed from the general ability to grasp an object with
to specific
whole palm, followed by using
only thumb and fore finger
 Growth proceeds from gross
muscle to fine muscle movement
7. There are individual rates  Growth rates are unique to each
of growth and development child
 Each child will grow at different
rate
 Factors Influencing
Growth and Development
Prenatal
environment

Postnatal Heredity/
environment genetics

Factors
Social
Gender economic
factors
Malfunction
of endocrine
systems

Student Activity: Read and find out more about these factors
 Physical Growth
 Physical growth divided into four phases

• Antenatal to 6 months old

Two phase:
• 12 to 16 years of age
rapid (During puberty)

• End of first year to

Two phase: puberty
slow • After puberty
 Assessment of Physical Growth

Parameters used to assess physical growth:

Anthropometry measurements
 Body weight
 Length or height
 Head circumference
 Chest circumference (excluded in the current practice)
 Anthropometry Measurements
Body weight
 Most sensitive indicator  Average weight of baby:
< 7 years old 2.7 to 3.4 kg
 Identify deviation from  10% of weight drops after
reference curves birth and regained at day 10
of life
 Weight compared to
 Weight gain :
• weight for age
• 1 to 6/12: 2 x birth weight
• Body Mass Index (BMI) (BW)
• 7/12 to 1 year: 3 x BW
• 2 years: 4 x BW
• 6 years: 6 x BW
 Anthropometry Measurements
Length
 Length is the
measurement taken when
baby is lying recumbent
 Measure from crown of Infantometer
the head to heel
 For children < two years

Measure length
 Anthropometry Measurements
Height
 Measurement taken when Growth Rate in Height
child is standing upright
Age Increase remarks
(vertical measurement of rate
object/body) By first year 30 cm 50% of birth
height
 Increase steadily: pubertal
By second 9–12 cm ½ of adult
spurt year height

 Indicators for nutritional During third 5–6.5 cm –

status year

 Malnutrition may not be Preschool

and school
4–6 cm/year –

observed in less than 6 children

months, need to rely on
other indicators
 Anthropometry Measurements
Measure height
 Anthropometry Measurements
Circumference of Head (COH)
 To detect hydrocephaly or microcephaly
 Parameter: past and current malnutrition status during
prenatal and early childhood
 Measure routinely up to two years
 Up to five years to detect or monitor hydrocephaly

Measure length, head & chest circumference

 Anthropometry Measurements

COH in centimetres (cm)

 33 - 37 cm at birth (35 cm)  Normal range in 5th to 9th
percentile of growth curve
 Increase 1 cm monthly
during 1st year  Delay in growth indicates
malnutrition
 Grow rapidly for 1st 8
months  Macrocephaly ( < 2 SD or <
3rd percentile of the norm)
 By 12 months is 70 % of
adult’s size  Hydrocephaly ( > 2 SD or
 90% of adult’s size at 7 > 97 percentile of the
years norm)
INTERPRETATION OF GROWTH CHART
 Growth Chart
 Growth indicators are used to assess growth considering
a child’s age and measurement of weight and height.
 Growth indicators for a child:
– Length/height-for-age
– Weight-for-age
– BMI (body mass index)-for-age
– Head circumference-for-age (from birth till 36 months old)
 The measurement will be plotted on growth charts:
– Boy’s Growth Chart Record (blue in colour)
– Girl’s Growth Chart Record (pink in colour)
37
 Growth Chart
The features of growth chart are:
 x-axis
– The horizontal line represent at the bottom of the graph
– Show age in months/years
 y-axis
– The vertical line at the far left of the graph
– Represent weight in kilograms, length/height in cm or
BMI (kg/m2)
 Plotted point
– The point on a graph where a line extended from a
measurement on the x-axis intersects with a line
extended from a measurement on the y-axis
 Growth Chart

y-axis

Plotted point

X-axis
 Growth Chart

 Weigh child each time the child visits clinic.

 The findings of the chart give a weight for age
curve.
 Interpretation of the graph represents the
nutritional status of the child.
 Objectives of Plotting a Growth Chart

1. Makes growth a tangible visible attribute

2. Enable monitoring of growth to promote health
among children
3. Diagnostic tool to identify high-risk children, e.g.
malnutrition
4. Educational tool for parents
5. Planning and policy tool
6. Tool for planning intervention
7. Evaluation of corrective measures
 BRAIN AEROBIC 1- Growth Chart for Amahl
1. What was Amahl’s
weight at 9 months?
8 kg
2. How old was Amahl
at the visit when he
weighed a little less
than 9 kg?
13 months
3. What was Amahl’s
age and weight at the
last visit shown?
18 months, 9.1kg

Source: WHO Training Course on Child Growth Assessment: Interpreting Growth Indicators.
(p.14)
INTERPRETATION OF GROWTH CHART
Interpret Plotted Points for Growth Indicator
 The curved lines printed on the growth chart helps to
interpret the plotted points that represent a child’s
growth status.
 The line labelled “0” represents the median / average.
 The other lines are z-score lines, also known as
standard deviation (SD) scores.
 Z-score lines on the growth chart are numbered
positive +1, +2, +3 or negative -1, -2, -3.
 Generally, a plotted point that is far from the median in
either direction may indicate a growth problem, although
other factors must be considered, such as the child’s
health condition and the height of the parents.
Interpret Plotted Points for Growth Indicator
Summary of growth problems:

Source: WHO Training Course on Child Growth Assessment: Interpreting Growth Indicators.
(p.22)
Interpret Plotted Points for Growth Indicator
Interpret Plotted Points for Growth Indicator

 To identify trends in a child’s growth, study the

points for growth indicators plotted at a series of
visits.
 Trends may indicate that a child is growing
consistently and well, or they may have growth
problems, or the child is at risk for a problem and
should be reassessed soon.
 In general, “normally” growing children follow
trends that are parallel to the median and z-score
lines. (Grow in a “track”, means the track may be
below or above the median, on or between z-score
lines and roughly parallel to the median.)
Interpret Plotted Points for Growth Indicator
 Be alert for the following trends which may indicate a
problem or risk:
i. A child’s growth crosses a z-score line
ii. A sharp incline or decline in the child’s growth line
iii. The child’s growth line remains flat (stagnant); meaning no
gain in weight
 Whether or not the above situations actually represent a
problem or risk depends on where the change in the growth
trend began and where it is headed. It is crucial to
consider the child’s health history when interpreting
trends on growth chart.
 For example:
‐ If a child has been ill and lost weight, a rapid gain (shown by a
sharp incline on the graph) can be good and indicate “catch-up
growth”
‐ If an overweight child has a slight decline or flat weight growth
trend towards the median may indicate desirable “catch-down”
Interpret Plotted Points for Growth Indicator
 Growth curve of the child is
compared to the reference
curve provided.
 It is presented in percentile SD Indication
or standard deviation (SD).
Within ± 2 SD Normal growth curve
(White space)
Note:
Above + 2 SD Possible overweight
Whether or not the growth (Pink space) (to determine obesity,
curve actually represent a need check BMI)
problem or risk depends on Within -2 SD & -3 Mild malnutrition
where the change in the
growth trend began and SD (Yellow space) (Kurang berat badan
where it is headed. –KBB)
< -3 SD (Pink space) Severe malnutrition
It is crucial to consider the (Kurang berat badan
child’s health history when teruk – KBBT)
interpreting trends on
growth chart.
Interpret Plotted Points for Growth Indicator

Trend of growth curve:

Normal
i. Normal curve curve
± 2 SD
– Children who are
growing and developing
normally will generally
be on or between ± 2
SD (z-scores)
– Child is doing well

Normal growth curve

Interpret Plotted Points for Growth Indicator

Pattern of growth curve:

ii. Flat (Stagnant)
– Signals growth failure
– Need to be alert
– Flattening shows persistent
failure to gain weight
– Early signs of malnutrition
– Need to observe closely as
weight may be picking up

Flattening or horizontal curve

Interpret Plotted Points for Growth Indicator

Pattern of growth curve:

iii. Incline or decline
• May indicate a problem or
suggest risk
• Assess severity of
condition
• Requires intervention as
appropriately

Falling or decrease curve

Interpret Plotted Points for Growth Indicator

Pattern of growth curve:

iv. Decline
and incline
again or ‘catch up
growth’
• Increase in rate of weight
gain after a flattening or
falling curve which shows
early signs of recovery

Catch-up growth
Interpret Plotted Points for Growth Indicator
Pattern of growth curve:
v. Crossing z-score lines
– The growth of a child plotted over time is expected to track
fairly close to the same z-score line.
– If crossing z-score lines, it indicates possible risk.
– The interpretation of risk is based on where the change
in trend began and the child’s health history.
– It the growth lines tends towards the median, this is probably
a good change.
– If it tends away from the median, this likely signals a
problem or risk.
– If the growth line is inclining or declining that it may cross a
z-score line soon, consider if the change may be
problematic.
INTERPRET OF GROWTH CURVE / TRENDS ON GROWTH CHART

Case example 1
• The first growth curve
generally track along +2 z-
score, crossing it from
time to time in a trend that
indicates no risk.

• The bottom growth line

shows a boy’s weight
falling away from his
expected growth track.
Although his growth line
remains between -1 and -
2 z-score, this boy has in
fact crossed z-score
following a systematic
trend that indicates risk.
INTERPRET OF GROWTH CURVE / TRENDS ON GROWTH CHART

• This boy’s weight-for-age

Case example 2
has stayed on a track
around the -2 z-score line
for 2 years.
• This consistency suggests
that he is gaining weight
normally and is simply a
“lean” child.
• However, it would be
important to look at his
height-for-age and BMI-for-
age chart as well.
• If he is a tall child, his BMI
chart could indicate a
problem.
INTERPRET OF GROWTH CURVE / TRENDS ON GROWTH CHART

Case example 3

• This boy’s weight-for-age

chart shows a sharp
decline from age 10 to 11
weeks, when he had
diarrhoea and lost 1.3 kg.

• After the episode of

diarrhoea, during re-
feeding, this boy gained
back most of the lost
weight. (“Catch-up
growth”)
INTERPRET OF GROWTH CURVE / TRENDS ON GROWTH CHART

Case example 4
• Malini’s weight-for-age chart
shows a flat growth line
(stagnation) form age 6 months
to 8 months and gained from
about 1 year and 4 months to 2
year-old.
• These periods of stagnation is
due to episodes of malaria
(indicated by arrows).
• From 8 months up to 1 year 4
months, she grew and gained
weight.
• Due to periods of stagnation,
Malini’s weight-for-age is about
to cross the -2 z-score line.
BRAIN AEROBIC 2
BRAIN AEROBIC 3
BRAIN AEROBIC 5
BRAIN AEROBIC 6
 Possible Causes of Growth Deviation
in Children
Inadequate intake of nutrition  Chronic disorders, congenital
 Poor intake heart problems, cleft palate,
renal disease or infection
 Inadequate feeding
 Emotional problems, abuse,
 Under- or over-dilution of neglected, separation from
milk parents or caretaker
 Delay in commencing  Misinterpretation in case of
complimentary diet Kwashiorkor as there will be
 Inappropriate increase in weight due to
complimentary diet oedema
 Child Development

 Child development is a process a child experiences

from prenatal till adulthood which involves a series
and sequence of learning processes to master skills
such as sitting, walking, jumping and running.
 It happens within the predictable time period.
 It is the evidence of mental and nervous system
maturation.
Purposes of Assessing the Child’s
Development
 To ascertain the level and pattern of development
according to age.
 To gather information to plan supervision and
anticipatory guidance in development.
 For early detection of any abnormal milestone.
 Six Domains of Child Development

• Ability to use large 2. Speech • Ability to understand

1. Gross muscle
language
3. • Delay speech may be
motor • E.g. Head control, walk
Hearing due to hearing defect

• Development of fine
4. or small muscle • Requires maturity in
• Requires intellect and physiology
Adaptive 6. Psycho- to interact with others
coordination of
vision social • Ability to solve
5. Vision • Uses finger to pick up problems
small objects
 Six Domains of Child Development
Gross Motor
 Emphasizes on the child’s
ability to use large muscles.
 Examples include a
newborn baby’s reflex, head
control, sitting, and standing
or walking with support.
 Six Domains of Child Development
Adaptive (Fine Motor) And Vision
Adaptive is fine motor development
which involves the development of fine or
small muscles.
Adaptive skills require coordination of
the vision ability.
Most common examples are using
hands and fingers to pick up small objects
like raisins and nuts, holding spoon,
turning pages in a book.
Infant’s
hand usually remains fisted till
six weeks of life.
 Six Domains of Child Development
Speech (language) and hearing
 Child’s ability to understand and use
language.
 Speech is the production of sound
 Involves comprehension and
expression of words, phrases and
gestures to convey an intended idea.
 Child needs to have a normal hearing
ability and cognitive skill for them to
understand the language used.
 Six Domains of Child Development
Psychosocial
 This skill requires maturity in
intellect and psychology of
children to enable them to
interact more with other
people and the external
environment .
 Personal and social
development enables children
to interact and respond to
their surroundings e.g. self-
control, smiling and waving at
people.
 Self-help skills
 Developmental Milestone

Sucking &
Grasp palmar & Stepping or
rooting
plantar Moro reflex walking

Swallowing Extrusion

Primitive reflexes
Developmental Milestone
Developmental Milestone
 Equipment for Developmental
Assessment

 Bell or rattle
 Red yarn
 Cubes
 Raisin
 Piece of thick paper board 30 cm x 22 cm with a
hole at the centre
 A picture book containing objects that are commonly
seen and the pages must be tick
 Equipment for developmental
assessment depending on age group

 One plastic pail

 A piece of paper with marker pen/pen/pencil
 A jigsaw puzzle with three shapes: round/rectangle/
triangle
 2½ metre long rope
 One medium-sized ball, a paper and pen
Note: Refer handouts for equipment used for
different age groups.
 Equipment for Developmental
Assessment
 In order to give optimum care to children, the nurse must
understand the concept of growth and development and the
principles underlining this concept to enable them to assess,
monitor and give proper health education to parents on child
care as well as parenting skills.
 Steps in Carrying Out Child Health Assessment

1. Gather information
– Study child health record
– Interview mother
2. Assess nutritional status (breastfeeding &
complimentary diet if applicable).
3. Assess 6 domains of child development according to
age group.
4. Carry out physical assessment from head to toe
systematically.
5. Assess physical growth by measuring anthropometry.
 Steps in Carrying Out Child Health Assessment

6. Provide health education appropriately based on

problems identified.
7. Give basic treatment as needed.
8. Refer to doctor (MO) if needed.
9. Immunization (according to immunization schedule).
10. Follow up appointment.
11. Documentation.
Steps in Carrying Out Child Health Assessment

Head to toe physical examination

- Fontanelle
 The posterior fontanelle
closes around 6 to 8 weeks.
 The anterior fontanelle
closes by 18 months old.
Steps in Carrying Out Child Health Assessment
 Case Study

AK, 6-month-old boy, visits your clinic for the first

time. He is well and active. Vaccination is up to
date. His weight is 6.8 kg, other measurements are
at the normal range. He has some heat rash under
his neck and arm folds, and has not started with
complementary diet yet.

Describe the activities that you need to plan and

carry out for AK and his mother during their visit.