Common Behavioural Problems in Infants and Role of The Nurse

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COMMON BEHAVIORAL PROBLEMS IN INFANTS BEHAVIOUR is the action or reaction of something under specified circumstances.  circumstances.  BEHAVIOR PROBLEM: Any PROBLEM: Any behavior that disturbs disturbs an individual’s ability to function adequately adequately will constitute a behavior problem. Separation anxiety   Separation anxiety is a developmental stage during which the child experiences anxiety when separated from the primary caregiver (usually the mother).

Before 8 months, infant becomes familiar with the home environment, and feels comfortable when parents or other known caretakers are present. After this time, lack of  familiarity often produces fear because the infant recognizes that something unusual is going on.

From 8 - 14 months, children often become frightened when they meet new people or  visit new places. They recognize their parents as familiar and safe. When separated from their parents, particularly when away from home, they feel threatened and unsafe.

Separation anxiety is a normal developmental stage. It usually ends when the child is around 2 years old.

Even after children have successfully mastered this developmental stage, separation anxiety may return during periods of stress. To get over separation anxiety, children must:




Excessive distress when separated from the primary caregiver  Nightmares Reluctance to go to sleep without the primary caregiver nearby

Management: 

There are no tests for this condition, because it is normal.

Parents can help their infant learn to adjust to their absence by letting trusted caregivers babysit the child. This helps the child learn to trust and bond with other adults and understand that their parents will return.

Encourage parents to have close friends and relatives to come often to accustom the infant to new people.

Encourage parents to reassure the infant of their presence through talking to infants when leaving the room, room, allowing them to hear one’s voice on the telephone and using transitory objects (e.g. a favourite blanket or toy.).


If severe separation anxiety persists past age 2, an evaluation with a psychiatrist may be needed to determine if the child has an anxiety disorder or other condition.

Stranger Anxiety   Stranger anxiety is fear or wariness of people with whom a child is not familiar.

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By about 6-7 months, the infant can differentiate between the primary caregiver and others leading to fear of unfamiliar people or strangers. The infant, when approached by some unfamiliar person, turns away, even cry or runs towards the primary caregiver.

Factors influencing child stranger fears: 

Gender, age, and size of the stranger- female, younger age and smaller size (include kneeling or sitting rather than standing) being less stressful  Approach (loud, sudden, intrusive approach causing more distress)   Child’s proximity to parent---parent---- closer to parent (on parent’s lap rather than in infant seat) being less stressful Management:      

Reassurance of parents is required that this behavior gradually declines. Infant is managed with relaxation technique such as slowly exposing them to the stranger, initially from the distance. Talk softly Meet the child at eye level (to appear smaller) Maintain safe distance from the infant Avoid sudden, intrusive gestures such as holding the arms out and smiling broadly.

Thumb & Finger Sucking 

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Sucking is an instinctual behavioral pattern. It starts during infancy and reaches its peak at 18-20 months. It is most prevalent when the child is hungry, sick, or tired to soothe themselves. Constant thumb sucking in a listless, apathetic child is strongly related to the emotional satisfaction of the infant or young child. It may be a sign of emotional problem between parent and child or of boredom, isolation and lack of stimulation. Finger sucking will not have any detrimental effect on the position of the permanent teeth, as long as the habit is discontinued before the secondary teeth have erupted. Malocclusion may occur if thumb sucking persists past 4-6 years or when the permanent teeth erupt

Complications: 

Teething problems


Respiratory problems

Gastro-intestinal problems

Palate changes

Teeth pushed forward

Buck teeth

Dental bite problems

Management: In most cases, thumb sucking represents a greater problem to the parents than to the child. The history usually reveals that the child does not do an unusual amount of thumb sucking; it is the parent who is made anxious by the behaviour. The child may benefit from the use of positive reinforcements for not sucking the thumb rather than negative statements regarding the behaviour.

Self Stimulation:  

It usually consists of the normal self-soothing habits of children and arises in early infancy. Such behaviors appear in two forms:   Rhythmic habits – habits –  include rocking, head rolling, head banging. Appearing in the second half of the first year, these behaviors usually occur at the time of fatigue, sleepiness, or frustration and serve as comfort to the child.

*Head banging typically occurs with the child lying face down – down  – banging the head down into a pillow or mattress. In an upright position, the head may bang against the wall or headboard repeatedly. *Head banging usually disappear by 18 months. *Banging can result in callus formation, abrasions and contusion.   Genital exploration or manipulation  –  –   The extent of this behaviour is directly correlated with age. In an infant or young child, genital manipulation is a manifestation of wholesome curiosity.

Management: 

Management of concerns regarding rhythmic behaviour is directed towards averting injury and reducing noise.


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Don’t attempt to discipline or restrain the young child once the behaviour has started.   Reassurance of the parents that head banging alone is not a sign of developmental disability Padding of the heard surface can decrease the chance of injury.

Breath holding attacks   A breath holding spell is an involuntary pause in breathing, sometimes accompanied by loss of consciousness. It usually occurs in response to an upsetting or surprising situation.

Child is usually intelligent and easily frustrated and reacts in a dramatic way to gain attention.  Rarely occur when the child is alone, as he needs an audience for the show.  An attack often starts with the child taking a very deep breath in as if he were going to scream, but instead he holds his breath and his face goes redder and redder and eventually turns blue.   The attacks aren’t usually danger ous, ous, although occasionally a very long attack can end

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with a convulsion or a short period of unconsciousness because the child’s brain does not get the required oxygen. Breath holding is seen in some normal children from as early as age 2 months, but it can start as late as 2 years old. Although they often occur with tantrums, breath holding spells are not thought to be a willful act of defiance. Children with iron deficiency anemia may also have increased episodes of breath holding. SEEK MEDICAL HELP: - When child may stop breathing for up to 1 minute (60 seconds) during a spell. -If child doesn't wake up quickly and doesn’t start breathing again.  again. 

Symptoms:: Symptoms   

Bluish discoloration of the skin caused by lack of oxygen (cyanosis) or loss of skin color  (pallor)   (pallor) Crying and then stopping breathing (apnea) Momentary unconsciousness or fainting o Short seizure-like movement (one to two jerks)

Possible Complication: 

The biggest risk is injury, especially head injury, due to a fall during a spell.


Management:      

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No treatment is usually necessary. Avoiding situations that provoke temper tantrums can help reduce the number of spells. Breath holding spells that do not cause the child to become unconscious are best ignored, in the same way temper tantrums are ignored. If child has an iron deficiency, should start iron replacement treatment. When a spell occurs, be sure that child is in a safe place where he or she won't be hurt during a fall or a brief seizure. After the spell, try to be calm and avoid giving too much attention to the child, because this can reinforce the behaviors that lead to the breath holding spells. Placing a cold cloth on child's forehead during the spell may shorten the episode. Reassurance of the parents that spell will not harm the child. Protect child during a spell, lay the child on the floor and keep his or her arms, legs, and head from hitting anything hard or sharp Try to distract him or her before the behavior reaches the point that typically provokes a spell.

Aggression   Aggressive/attacking behaviour is a protective mechanism, necessary for  survival instinct. It enables us to cope with problems we face. It is present from birth onwards thus a child needs to be trained to control it.

Babies if not fed and hungry, scream and wave their arms and legs about, as this is the only way they can convey their needs. If you meet your babies need right away they are less likely to react in this manner to every frustrating situation, as they grow older. A baby who is made to wait generally calms down but his anger and aggression are then directed elsewhere or contained and expressed internally and manifest as failure to thrive etc.

Reference: Wong. (2007). Nursing Care of Infants and Children. Singapore: Elsevier. Stafford B, Boris NW, Dalton R. Anxiety disorders. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 24.   Feigelman S. The first year. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Textbook of Pediatrics.

18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 8.  



Role of the Nurse in the Care of a Healthy/Ill Newborn 1. The nurse is responsible for the newborn’s first checks and confirms newborn’s identification and records all significant information.  information.  2. Maintenance of a clear airway and stable vital signs. - Reinforce teaching about choking, positioning, temperature maintenance with clothing and blankets. Teach infant positioning to facilit facilitate ate breathing and digestion, holding and feeding skills, soothing and calming techniques. In the absence of any newborn distress, the nurse continues taking the vital signs.  signs. 

3. Prevention of complications of diseases of newborn. -  Newborn’s are at continued risk for the complication of hemorrhage, late onset cardiac symptoms and infection. Hand washing or the use of of antiseptic hand hand cleaner before touching the baby should be observe to prevent infection . 4. Initiation of first feeding. -

Encourage breastfeeding during the first period of reactivity. Teach positions; observe/assist with feeding, breast/nipple care, establishing milk supply, feeding cues and burping.

5. Promotion of Adequate Hydration and Nutrition The nurse records caloric and fluid intake and enhances adequate hydration by maintaining a neutral environment and offering easy and frequent feeding. Weight should be taken for comparison. comparison . 6. Facilitation Facilitati on of Parent-Newborn Parent-Newbor n attachment -

The nurse encourages parent-newborn attachment involving both parents with the new family member by: a. Present information on periods of reactivity and expected newborn responses. b. Describe normal physical characteristics of the newborn. c. Explain the bonding process, its gradual development, and the reciprocal interactive nature of the process. d. Discuss the infant’s capabilities for interaction, such as nonverbal communication communicatio n abilities. e. Explain that touching, including stroking, patting, massaging, and kissing, will progress to interactive touch between the parents and their infant. f. Describe and demonstrate comforting techniques, including the use of  sounds, swaddling, rocking, massage, and stroking.


g. Describe the progression of the infant’s behaviors as the infant matures and the importance of the parents’ consistent response to their infant’s cues and needs. h. Provide information about available pamphlets, videos, and support group in the community.

7. Maintenance of Neutral Thermal Environment  A neutral thermal thermal environment environment is is essential essential to minimize minimize the need for increased increased oxygen consumption and use of calories to maintain body heat. a. Keep the newborn’s clothing warm and dry.  dry.   b. Double wrap the newborn and put a cap. c. Warm objects that will be in contact with the newborn. (eg. stethoscope) d. Encourage the mother to snuggle with the newborn under blankets or breastfeed the newborn with cap and light cover on. e. Warm formula or stored milk before feeding. f. Monitor the baby’s skin temperature.  temperature.  8. Promotion of skin integrity by newborn skin care including bathing bathing and cleansing of buttocks and perineal areas. Newborn skin care is important for the health and appearance of the individual newborn and for infection control within the nursery. 9. Promotion of Safety It is essential that the nurse and other caregivers verify the identity of the newborn by comparing the numbers and names on the identification bracelets of  mother and newborn before giving a baby to a parent. Observe for fall and safety precautions with handling and caring for the infant. For car safety, nurses should instruct that newborns should never be placed in the front seat of a car equipped with passenger-side airbag. It should be placed on the back seat and position to face the rear of the car with proper installation of  safety seat. 10. Newborn Screening and immunization Programs The nurse informs about the importance of newborn screening test and immunization program and tells them when to return to birthing center or clinic.



Ladewig, L. D. (2006). (2006). A  A Look at Contemporary Maternal –  Newborn Nursing Care Sixth Edition. Pearson Education South Asia PTE. LTD.



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