👦🧫 Childhood Disorders – Tonsillitis

📘 Essential for Pediatric Nursing, ENT Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Tonsillitis is the inflammation of the palatine tonsils, commonly caused by viral or bacterial infections, resulting in sore throat, fever, and difficulty swallowing.

✳️ Tonsils are lymphoid tissues located at the back of the throat that help fight infections — until they themselves become infected.

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🧭 Types of Tonsillitis:

Type	Description	Common Cause
🟩 Acute Tonsillitis	Sudden onset, resolves in 7–10 days	Group A Streptococcus (GAS), adenovirus
🟥 Chronic Tonsillitis	Recurrent or persistent inflammation	Inadequately treated infections
🟨 Recurrent Tonsillitis	≥ 7 episodes/year or ≥ 5/year for 2 years	Multiple acute infections

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🧠 Causes of Tonsillitis:

🟩 Viral Causes (Most Common):

• Adenovirus
• Influenza virus
• Rhinovirus
• Epstein-Barr virus (EBV)

🟥 Bacterial Causes:

• Group A β-hemolytic Streptococcus (GABHS) (most common bacterial agent)
• Staphylococcus aureus
• Haemophilus influenzae

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📌 Predisposing Factors:

• Poor oral hygiene
• Frequent upper respiratory infections
• Close contact in schools or daycares
• Exposure to allergens or irritants (e.g., smoke)

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⚠️ Clinical Features:

System	Signs & Symptoms
🟥 Local	Sore throat, swollen/red tonsils, white/yellow patches on tonsils
🟨 Systemic	Fever, headache, chills, body aches
🟩 ENT	Painful swallowing (odynophagia), muffled voice, bad breath
🟦 General	Enlarged cervical lymph nodes, fatigue, refusal to eat (in children)

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🧪 Diagnostic Evaluation:

🟢 Throat examination – Red, enlarged tonsils with/without exudates
🟢 Throat swab & culture – To detect Streptococcus
🟢 Rapid Antigen Detection Test (RADT) – For quick Strep diagnosis
🟢 CBC – Leukocytosis suggests bacterial cause
🟢 Monospot test – If EBV suspected (infectious mononucleosis)

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💊 Medical Management:

✅ 1. Supportive Care:

• Bed rest
• Warm saline gargles
• Adequate fluid intake
• Soft diet
• Analgesics and antipyretics (Paracetamol, Ibuprofen)

✅ 2. Antibiotic Therapy (for bacterial):

• First-line: Penicillin or Amoxicillin × 10 days
• If allergic: Azithromycin or Erythromycin

✅ 3. Tonsillectomy Indications (Surgery):

• ≥7 episodes/year or chronic tonsillitis
• Obstructive sleep apnea
• Peritonsillar abscess (quinsy)
• Difficulty swallowing/breathing due to enlarged tonsils

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👩‍⚕️ Nursing Management:

🟩 Assessment:

• Monitor throat condition and vital signs
• Check for signs of airway obstruction
• Note dietary intake and hydration

🟨 Interventions:

• Provide warm fluids and soft diet
• Encourage salt water gargles if age-appropriate
• Administer medications as prescribed
• Educate on hand hygiene and avoiding shared utensils
• Monitor for complications: abscess, dehydration

🟥 Post-Tonsillectomy Care:

• Position child side-lying to prevent aspiration
• Avoid red-colored fluids (may mimic blood)
• Ice collar for pain
• Observe for bleeding (frequent swallowing, vomiting blood)
• Avoid hot/spicy foods and straws for 10 days

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🚨 Complications:

❌ Peritonsillar abscess (quinsy)
❌ Rheumatic fever
❌ Glomerulonephritis
❌ Otitis media
❌ Airway obstruction
❌ Post-op hemorrhage

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📚 Golden One-Liners for Quick Revision:

🟡 Most common bacterial cause = Group A Streptococcus
🟡 Antibiotics = Penicillin or Amoxicillin (10 days)
🟡 Tonsillectomy if recurrent or obstructive
🟡 Warm salt gargle = supportive care
🟡 Avoid red fluids after tonsillectomy

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✅ Top 7 MCQs for Practice:

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Q1. Most common bacterial cause of tonsillitis in children is:
🅰️ Staphylococcus
✅ 🅱️ Group A Streptococcus
🅲️ Haemophilus
🅳️ Pseudomonas
Correct Answer: 🅱️ Group A Streptococcus

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Q2. Which is an indication for tonsillectomy?
🅰️ 1–2 episodes/year
🅱️ Mild sore throat
✅ 🅲️ ≥ 7 episodes/year
🅳️ Occasional fever
Correct Answer: 🅲️ ≥ 7 episodes/year

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Q3. White patches on tonsils suggest:
🅰️ Viral infection only
✅ 🅱️ Bacterial tonsillitis
🅲️ Dehydration
🅳️ Malnutrition
Correct Answer: 🅱️ Bacterial tonsillitis

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Q4. Best position after tonsillectomy is:
🅰️ Supine
✅ 🅱️ Side-lying
🅲️ Prone
🅳️ High Fowler’s
Correct Answer: 🅱️ Side-lying

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Q5. Red flag sign after tonsillectomy is:
🅰️ Snoring
🅱️ Loss of appetite
✅ 🅲️ Frequent swallowing
🅳️ Low-grade fever
Correct Answer: 🅲️ Frequent swallowing

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Q6. Which test is used for quick diagnosis of Streptococcal tonsillitis?
🅰️ Mantoux test
✅ 🅱️ Rapid antigen detection test
🅲️ Widal test
🅳️ Monospot
Correct Answer: 🅱️ Rapid antigen detection test

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Q7. Warm saline gargle helps by:
🅰️ Curing the infection
✅ 🅱️ Reducing throat pain and inflammation
🅲️ Increasing immunity
🅳️ Causing dehydration
Correct Answer: 🅱️ Reducing throat pain and inflammation

👂👦 Childhood Disorders – Otitis Media

📘 Essential for Pediatric Nursing, ENT Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Otitis media is an inflammation or infection of the middle ear, commonly seen in infants and young children, and is often associated with upper respiratory tract infections (URTI).

✳️ It may be acute, chronic, or with effusion, and may affect one or both ears.

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🧭 Types of Otitis Media:

Type	Description	Feature
🟥 Acute Otitis Media (AOM)	Sudden onset of middle ear infection	Pain, fever, bulging tympanic membrane
🟨 Otitis Media with Effusion (OME)	Fluid in middle ear without infection	Hearing loss, no fever or pain
🟩 Chronic Otitis Media	Long-term infection with ear discharge	Tympanic membrane rupture, hearing loss
🟦 Recurrent Otitis Media	≥3 episodes in 6 months or ≥4 in 1 year	Common in bottle-fed babies, passive smoking exposure

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🧠 Causes of Otitis Media:

🟥 Infectious Organisms:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Respiratory viruses (RSV, influenza)

🟨 Risk Factors:

• Age < 3 years
• Bottle feeding (supine position)
• Exposure to tobacco smoke
• Pacifier use
• Day-care attendance
• Allergies or URTI

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⚠️ Clinical Features:

Stage	Symptoms
🟥 Early	Ear pain (otalgia), fever, irritability, poor feeding, tugging/pulling ear
🟨 Advanced	Hearing loss, discharge (otorrhea), congestion, bulging eardrum
🟦 Chronic	Perforation of tympanic membrane, foul-smelling discharge, delayed speech

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🧪 Diagnostic Evaluation:

🔹 Otoscopy – red, bulging tympanic membrane, decreased mobility
🔹 Tympanometry – detects fluid in middle ear
🔹 Audiometry – in older children to assess hearing loss
🔹 Culture of ear discharge – in chronic cases

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💊 Medical Management:

✅ 1. Acute Otitis Media:

• Analgesics/Antipyretics: Paracetamol, Ibuprofen
• Antibiotics (if bacterial suspected):
  • First-line: Amoxicillin × 7–10 days
  • If allergic: Azithromycin, Cefuroxime

✅ 2. Otitis Media with Effusion (OME):

• Observation (“watchful waiting”) for 3 months
• Auto-inflation techniques
• Myringotomy with grommet insertion (if persistent)

✅ 3. Chronic Cases:

• Aural toilet (ear cleaning)
• Topical antibiotics
• Surgery: Tympanoplasty, Mastoidectomy

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👩‍⚕️ Nursing Management:

🟩 Assessment:

• Monitor ear pain, fever, discharge
• Check feeding behavior and crying pattern
• Ask about speech/language delay

🟨 Interventions:

• Apply warm compress over the affected ear
• Ensure correct positioning during feeding (hold upright)
• Administer prescribed medications
• Prevent water entry into ears (bathing, swimming)
• Educate parents on early signs of hearing loss

🟥 Parent Teaching:

• Avoid bottle feeding in lying position
• Complete antibiotic course even if symptoms improve
• Promote immunization (Pneumococcal, Influenza)
• Reduce passive smoke exposure

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🚨 Complications:

❌ Hearing impairment
❌ Tympanic membrane perforation
❌ Mastoiditis
❌ Delayed speech and language development
❌ Meningitis (rare but serious)

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📚 Golden One-Liners for Quick Revision:

🟡 Otitis media = most common ear disorder in children
🟡 AOM = painful + fever; OME = painless but affects hearing
🟡 Risk ↑ with bottle feeding, day care, and smoke exposure
🟡 First-line antibiotic = Amoxicillin
🟡 Grommet insertion = for persistent OME with hearing loss

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✅ Top 7 MCQs for Practice:

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Q1. Which of the following is the most common cause of otitis media in children?
🅰️ E. coli
🅱️ Pseudomonas
✅ 🅲️ Streptococcus pneumoniae
🅳️ Salmonella
Correct Answer: 🅲️ Streptococcus pneumoniae

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Q2. Which symptom suggests acute otitis media?
🅰️ Seizures
✅ 🅱️ Ear pain with fever
🅲️ Dry cough
🅳️ Rash
Correct Answer: 🅱️ Ear pain with fever

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Q3. Most appropriate antibiotic for acute otitis media:
🅰️ Ciprofloxacin
✅ 🅱️ Amoxicillin
🅲️ Metronidazole
🅳️ Gentamicin
Correct Answer: 🅱️ Amoxicillin

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Q4. Hearing loss without pain in otitis media is seen in:
🅰️ Acute otitis media
🅱️ Chronic otitis media
✅ 🅲️ Otitis media with effusion
🅳️ Mastoiditis
Correct Answer: 🅲️ Otitis media with effusion

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Q5. Recurrent otitis media is defined as:
🅰️ 2 episodes/year
🅱️ 5 episodes in 2 years
✅ 🅲️ ≥ 3 episodes in 6 months or ≥ 4/year
🅳️ 1 episode/month
Correct Answer: 🅲️ ≥ 3 episodes in 6 months or ≥ 4/year

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Q6. Which technique helps clear OME fluid?
🅰️ Antacids
🅱️ Cold compress
✅ 🅲️ Auto-inflation
🅳️ Eustachian cutting
Correct Answer: 🅲️ Auto-inflation

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Q7. Best feeding position to reduce otitis media risk:
🅰️ Supine
🅱️ Prone
✅ 🅲️ Upright
🅳️ Trendelenburg
Correct Answer: 🅲️ Upright

🚨👶 Childhood Disorders – Child Abuse

📘 Essential for Pediatric Nursing, Mental Health Nursing, Community Health, Forensic Nursing, GNM/BSc Nursing, NHM, AIIMS, GPSC, Staff Nurse Exams

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🔰 Definition:

Child abuse refers to any act or failure to act by a parent, caregiver, or other adult, that results in harm, potential for harm, or threat of harm to a child’s health, survival, dignity, or development.

✳️ Child abuse may be physical, emotional, sexual, or neglectful, and may occur in homes, schools, or institutions.

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🧭 Types of Child Abuse:

Type	Description	Examples
🟥 Physical Abuse	Intentional physical injury	Hitting, burning, shaking, choking
🟨 Emotional Abuse	Damaging a child’s self-worth	Verbal insult, rejection, isolation
🟪 Sexual Abuse	Using a child for sexual gratification	Incest, rape, fondling, child pornography
🟩 Neglect	Failure to meet basic needs	Malnutrition, abandonment, medical neglect
🟦 Munchausen Syndrome by Proxy	Caregiver induces illness in child	Fabricating symptoms for attention

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⚠️ Risk Factors:

🔹 Family stress, poverty
🔹 Parental substance abuse
🔹 Mental illness in caregiver
🔹 History of abuse in parent
🔹 Child with disability or chronic illness
🔹 Lack of support or education

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📌 Warning Signs (General):

Type	Signs
🟥 Physical	Bruises, burns, fractures, bite marks, scars
🟨 Emotional	Withdrawal, low self-esteem, excessive fear or aggression
🟪 Sexual	Genital injury, bleeding, STD, inappropriate sexual behavior
🟩 Neglect	Dirty clothes, underweight, untreated illness, poor hygiene

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🧪 Assessment & Evaluation:

🔍 Detailed history & interview with child and caregiver
🔍 Full physical examination – note injuries, hygiene, growth
🔍 Developmental assessment
🔍 Forensic evidence collection in sexual abuse (if applicable)
🔍 Use of screening tools (e.g., Child Abuse Potential Inventory – CAPI)

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📜 Legal & Ethical Aspects (India):

🟢 Key Laws:

• POCSO Act (2012) – Protection of Children from Sexual Offences
• JJ Act (2015) – Juvenile Justice (Care and Protection of Children) Act
• Section 75 IPC – Cruelty to child
• Mandatory Reporting – It is a legal obligation to report suspected child abuse

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💊 Medical Management:

• Treat injuries – wound care, fracture stabilization, pain management
• Psychological support – trauma-focused CBT, play therapy
• Post-exposure prophylaxis (PEP) – if sexual abuse suspected (HIV, STDs)
• Counseling – both child and caregiver (if non-offender)
• Hospitalization – in severe physical or mental trauma

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👩‍⚕️ Nursing Management:

🟩 Assessment:

• Observe child’s behavior, appearance, and interaction with caregiver
• Note inconsistencies between history and injuries
• Use open-ended, non-leading questions when interviewing

🟨 Intervention:

• Provide physical and emotional safety
• Document all findings objectively (e.g., size, location of injuries)
• Report suspected abuse to Child Welfare Committee (CWC) or legal authority
• Ensure privacy and confidentiality
• Collaborate with social worker, psychologist, and child protection unit

🟥 Health Education:

• Teach parents about positive discipline
• Raise awareness about child rights and abuse prevention
• Support school and community-based child protection programs

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🚨 Complications of Abuse:

❌ PTSD
❌ Depression, anxiety
❌ Suicidal behavior
❌ Poor school performance
❌ Substance abuse
❌ Personality disorders
❌ Delayed growth and development

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📚 Golden One-Liners for Quick Revision:

🟡 POCSO = Protection from Sexual Offenses (India)
🟡 Abuse can be physical, emotional, sexual, or neglectful
🟡 Nurses must report suspected child abuse – it’s mandatory
🟡 Munchausen by proxy = caregiver induces illness in child
🟡 Early detection prevents long-term psychological trauma

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✅ Top 7 MCQs for Practice:

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Q1. Which act protects children from sexual offences in India?
🅰️ MTP Act
🅱️ RTE Act
✅ 🅲️ POCSO Act
🅳️ PNDT Act
Correct Answer: 🅲️ POCSO Act

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Q2. Physical signs of abuse may include:
🅰️ Clean clothes
🅱️ Good eye contact
✅ 🅲️ Bruises and fractures
🅳️ Healthy appetite
Correct Answer: 🅲️ Bruises and fractures

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Q3. Munchausen syndrome by proxy is:
🅰️ Child pretends to be ill
✅ 🅱️ Caregiver induces illness in child
🅲️ Faking injury for insurance
🅳️ ADHD in children
Correct Answer: 🅱️ Caregiver induces illness in child

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Q4. Emotional abuse signs include:
🅰️ Fever
🅱️ Vomiting
✅ 🅲️ Low self-esteem and withdrawal
🅳️ Swollen joints
Correct Answer: 🅲️ Low self-esteem and withdrawal

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Q5. Nurses should document:
🅰️ Suspicions without details
✅ 🅱️ Objective findings like injury size, color
🅲️ Just opinions
🅳️ Verbal comments only
Correct Answer: 🅱️ Objective findings like injury size, color

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Q6. Reporting of child abuse by a nurse in India is:
🅰️ Optional
🅱️ Punishable
✅ 🅲️ Mandatory
🅳️ Discouraged
Correct Answer: 🅲️ Mandatory

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Q7. A nurse observes a withdrawn child with multiple healed fractures. Next step is:
🅰️ Send home immediately
✅ 🅱️ Report suspected abuse
🅲️ Ignore
🅳️ Just give medicine
Correct Answer: 🅱️ Report suspected abuse

😮‍💨🧒 Childhood Disorders – Breath Holding Spells (Spasms)

📘 Essential for Pediatric Nursing, Community Health Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Breath Holding Spells (BHS) are involuntary, non-epileptic episodes in which a child briefly stops breathing, usually in response to emotional triggers like frustration, anger, or pain.

✳️ Most commonly occurs in children aged 6 months to 6 years, with peak incidence at 1–2 years.

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🧭 Types of Breath Holding Spells:

Type	Description	Color Change
🟦 Cyanotic	Triggered by anger or crying → breath-holding → bluish skin	Cyanosis (blue lips, face)
🟥 Pallid	Triggered by pain or fright → vagal overactivity → fainting	Pallor (pale face, lips)
🟨 Mixed	Features of both cyanotic and pallid types	Cyanosis + Pallor

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⚠️ Key Characteristics:

✅ Episodes are brief (less than 1 minute)
✅ Child usually recovers spontaneously
✅ May appear limp or unconscious temporarily
✅ No postictal confusion (unlike seizures)
✅ Frequency: occasional to multiple times/week
✅ Commonly stops by age 5–6 years

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🧠 Causes / Triggers:

🔹 Sudden crying due to frustration or anger
🔹 Pain (e.g., fall, injury)
🔹 Fear or fright
🔹 Minor trauma
🔹 Emotional stress or tantrums

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📌 Risk Factors:

🔸 Family history of BHS
🔸 Iron deficiency anemia
🔸 Temperamental or highly sensitive child
🔸 Over-reactive parenting style

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🧪 Differential Diagnosis (Rule Out):

🟦 Epilepsy
🟦 Syncope
🟦 Cardiac arrhythmias
🟦 Seizure disorders
🟦 Sudden Infant Death Syndrome (SIDS) – if <6 months

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🔬 Investigations (Only if atypical or severe):

• CBC + Serum ferritin – to assess iron status
• ECG or EEG – if prolonged loss of consciousness or jerking
• Video EEG – to differentiate from seizures (if uncertain)

Routine testing is not required in classic cases.

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💊 Medical Management:

✅ Supportive:

• Reassure parents: the condition is benign and self-limiting
• Educate on episode pattern and safe handling
• Avoid reinforcing behavior by overreacting

✅ Pharmacological (If severe):

• Iron supplementation (if iron deficiency present)
• Atropine (rarely used in severe pallid type)
• No need for anticonvulsants unless seizures are confirmed

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👩‍⚕️ Nursing Management:

🟩 During an Episode:

• Stay calm and reassure caregivers
• Place child in a safe, flat position
• Do not shake, slap, or give water
• Loosen tight clothing
• Observe time duration, breathing pattern

🟨 After an Episode:

• Monitor consciousness, color, and breathing
• Offer comfort but avoid over-pampering
• Avoid giving in to tantrums or reinforcing attention

🟥 Education to Parents:

• Condition is not harmful and usually outgrown
• Avoid punishment or excessive attention after episode
• Recognize triggers and redirect child’s emotion early
• Emphasize iron-rich diet or supplements
• Keep floors and surroundings safe for fainting

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🚨 Complications (Rare):

❌ Injury due to falls
❌ Prolonged unconsciousness (uncommon)
❌ Seizure-like activity (in prolonged episodes)
❌ Parental anxiety and overprotection
❌ Rarely, breath-holding attacks associated with iron deficiency

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📚 Golden One-Liners for Quick Revision:

🟡 BHS = Non-epileptic, brief loss of breathing
🟡 Cyanotic = Crying trigger; Pallid = Pain trigger
🟡 Common in 6 months–6 years; benign and self-limited
🟡 Iron deficiency may worsen frequency and intensity
🟡 No need for medication unless atypical or frequent

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✅ Top 7 MCQs for Practice:

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Q1. Breath holding spells typically occur in children aged:
🅰️ < 3 months
🅱️ 10–15 years
✅ 🅲️ 6 months to 6 years
🅳️ Neonates only
Correct Answer: 🅲️ 6 months to 6 years

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Q2. Cyanotic breath holding spells are usually triggered by:
🅰️ Pain
✅ 🅱️ Crying or anger
🅲️ Sleep
🅳️ Hunger
Correct Answer: 🅱️ Crying or anger

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Q3. The most important first aid during a breath holding episode is:
🅰️ Offer sugar water
🅱️ Shake the child
✅ 🅲️ Lay child safely flat and observe
🅳️ Splash cold water
Correct Answer: 🅲️ Lay child safely flat and observe

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Q4. Which nutrient deficiency is associated with increased BHS frequency?
🅰️ Calcium
✅ 🅱️ Iron
🅲️ Zinc
🅳️ Magnesium
Correct Answer: 🅱️ Iron

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Q5. Which of the following differentiates BHS from seizures?
🅰️ Postictal confusion present
🅱️ Aura before episode
✅ 🅲️ No postictal confusion in BHS
🅳️ Lasts more than 5 minutes
Correct Answer: 🅲️ No postictal confusion in BHS

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Q6. Which of the following is FALSE regarding breath holding spells?
🅰️ Common in toddlers
🅱️ May lead to seizures in most cases
✅ 🅲️ Usually self-limiting
🅳️ Often linked to emotions
Correct Answer: 🅱️ May lead to seizures in most cases

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Q7. Which medication is used in rare severe pallid BHS?
🅰️ Diazepam
🅱️ Phenytoin
✅ 🅲️ Atropine
🅳️ Iron chelators
Correct Answer: 🅲️ Atropine

💦🛏️ Childhood Disorders – Enuresis (Bedwetting)

📘 Important for Pediatric Nursing, Mental Health Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Enuresis is the involuntary passage of urine in a child who is old enough to have bladder control, typically after the age of 5 years, in the absence of any organic cause.

✳️ Enuresis = “Repeated bedwetting or wetting of clothes in a socially unacceptable time or place.”

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🧭 Classification of Enuresis:

Type	Description	Example
🟩 Primary Enuresis	Child has never achieved bladder control	Bedwetting since infancy
🟨 Secondary Enuresis	Occurs after at least 6 months of dryness	Triggered by stress, infection
🟥 Nocturnal Enuresis	Urination during sleep	Common bedwetting at night
🟦 Diurnal Enuresis	Urination during daytime	School-age child wets pants in class
🟪 Mixed	Both day and night enuresis	Seen in emotional or developmental issues

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🧠 Possible Causes:

🟨 Physiological / Organic Causes:

• Delayed bladder maturation
• Urinary tract infection (UTI)
• Constipation
• Sleep apnea or deep sleep
• Small bladder capacity
• Genetic predisposition

🟥 Psychological Causes:

• Stress (new sibling, school fear)
• Emotional disturbance or trauma
• Parental conflict
• Low self-esteem or anxiety

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⚠️ Risk Factors:

🔹 Family history of enuresis
🔹 Male gender (3:1 ratio)
🔹 ADHD or learning disabilities
🔹 Poor toilet training
🔹 Inconsistent parental discipline

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📌 Clinical Features:

Feature	Observation
💦 Urination	Involuntary, intermittent, usually at night
🛏️ Age	>5 years with continued bedwetting
😴 Sleep	Deep sleeper, unaware of bladder fullness
🧠 Emotional	Embarrassment, guilt, low self-esteem
🧫 Physical	May have signs of UTI or constipation (if secondary cause)

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🧪 Diagnostic Evaluation:

🔬 Urine routine/microscopy – Rule out UTI
🔬 Ultrasound KUB – To assess bladder/kidney anomalies
🔬 Voiding diary – Frequency, volume, timing of wetting
🔬 Psychological assessment – If emotional factors suspected
🔬 Developmental screening – Rule out intellectual disability or ADHD

Most cases are functional and don’t need extensive investigations.

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💊 Medical & Behavioral Management:

✅ Behavioral Therapy (First-line):

• Motivational therapy – praise for dry nights
• Bladder training – increase bladder capacity
• Bedwetting alarms – wake child when urination begins
• Reward charts – stars/stickers for dry nights
• Scheduled waking – wake child to urinate during the night

✅ Medications (If behavioral fails):

• Desmopressin (DDAVP): ↓ urine production at night
• Imipramine (TCA): rarely used; risk of side effects
• Oxybutynin: anticholinergic – used for small bladder capacity

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👩‍⚕️ Nursing Management:

🟩 Assessment:

• Age of toilet training, dryness history
• Wetting pattern – time, frequency
• Behavioral/emotional concerns
• Family dynamics and support system

🟨 Interventions:

• Educate parents on normalcy and recovery
• Avoid punishment or embarrassment
• Encourage regular toilet schedule
• Promote hydration in daytime, restrict fluids 1–2 hrs before bed
• Assist with reward system implementation
• Maintain dry, clean environment and bedding

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🚨 Complications (If untreated):

❌ Social embarrassment
❌ Poor school performance
❌ Low self-esteem
❌ Depression or anxiety
❌ Family stress and conflict

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📚 Golden One-Liners for Quick Revision:

🟡 Enuresis = bedwetting after age 5
🟡 Primary = child never dry; Secondary = dryness relapsed
🟡 Nocturnal enuresis = most common form
🟡 First-line = behavioral therapy, bladder training, alarms
🟡 DDAVP = drug of choice if needed

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✅ Top 7 MCQs for Practice:

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Q1. Enuresis is best defined as:
🅰️ Daytime sleepiness
🅱️ Voluntary urination
✅ 🅲️ Involuntary urination in a child >5 years
🅳️ Painful urination
Correct Answer: 🅲️ Involuntary urination in a child >5 years

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Q2. Which type is most common in children?
🅰️ Diurnal
✅ 🅱️ Nocturnal
🅲️ Secondary
🅳️ Mixed
Correct Answer: 🅱️ Nocturnal

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Q3. Desmopressin helps by:
🅰️ Increasing urine
✅ 🅱️ Reducing nighttime urine production
🅲️ Causing sleep
🅳️ Stimulating bladder contraction
Correct Answer: 🅱️ Reducing nighttime urine production

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Q4. Which therapy is most effective first line for enuresis?
🅰️ Antidepressants
🅱️ Surgery
✅ 🅲️ Behavioral therapy
🅳️ Sedation
Correct Answer: 🅲️ Behavioral therapy

---

Q5. Common psychological feature in enuretic children is:
🅰️ Aggression
🅱️ Schizophrenia
✅ 🅲️ Low self-esteem
🅳️ Intellectual disability
Correct Answer: 🅲️ Low self-esteem

---

Q6. What is an important nursing teaching point in enuresis?
🅰️ Punish child for bedwetting
🅱️ Force early toilet training
✅ 🅲️ Avoid blaming, promote positive reinforcement
🅳️ Restrict daytime fluids
Correct Answer: 🅲️ Avoid blaming, promote positive reinforcement

---

Q7. A 6-year-old with recent-onset bedwetting may have:
🅰️ Primary enuresis
✅ 🅱️ Secondary enuresis
🅲️ No issue
🅳️ Night terror
Correct Answer: 🅱️ Secondary enuresis

💅😬 Childhood Behavioral Issue – Nail Biting (Onychophagia)

📘 Important for Pediatric Nursing, Mental Health Nursing, Community Health, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Nail biting (Onychophagia) is a repetitive and compulsive behavioral habit in which a child bites their fingernails, often unconsciously, as a response to stress, anxiety, boredom, or concentration.

✳️ It is considered a nervous habit and one of the most common body-focused repetitive behaviors (BFRBs) in childhood.

---

🧭 Classification:

Type	Description
🟩 Mild/Transient	Occurs occasionally without emotional issues
🟨 Habitual/Moderate	Associated with concentration or anxiety
🟥 Severe/Pathological	Interferes with daily functioning or causes injury; may be linked to OCD or anxiety disorders

---

🧠 Etiology / Causes:

🔹 Psychological Triggers:

• Anxiety, tension, stress
• Boredom, inactivity
• Lack of parental attention
• Performance pressure (school, exams)

🔹 Learned Behavior:

• Observing others (siblings, parents)
• Coping strategy for discomfort

🔹 Neurological Link:

• May be associated with OCD, ADHD, or tic disorders in some children

---

⚠️ Risk Factors:

🔸 Ages 3–10 years (most common onset)
🔸 Family history of nail biting or anxiety
🔸 Parental criticism or overcontrol
🔸 Changes in environment (school, divorce, new sibling)

---

📌 Clinical Features:

Observation	Details
💅 Physical	Short, damaged nails; redness or bleeding of nail bed
😬 Behavioral	Repetitive biting, often during stress or deep thought
🧠 Psychological	Anxiety, embarrassment, low confidence
🦠 Medical	Risk of infections – paronychia, dental issues, intestinal parasites (if poor hygiene)

---

🧪 Differential Diagnosis / Assessment:

• Observe triggers and frequency
• Rule out obsessive-compulsive tendencies
• Check for other habits (hair pulling, skin picking)
• Examine for secondary infections

---

💊 Management:

✅ 1. Behavioral Therapy (Primary):

• Habit Reversal Therapy (HRT): teach alternate behavior (e.g., fist clenching)
• Self-monitoring charts (record when and why biting occurs)
• Positive reinforcement – reward system for bite-free days
• Stress-reducing techniques – deep breathing, art, physical play
• Parental modeling and support

✅ 2. Pharmacological Therapy (only if OCD/severe anxiety present):

• SSRIs (e.g., Fluoxetine) – in diagnosed OCD cases
• Not routinely indicated for simple nail biting

---

👩‍⚕️ Nursing Management:

🟩 Assessment:

• Identify triggers, timing, emotional state
• Look for associated behaviors (e.g., lip biting, hair pulling)
• Observe parent-child interaction

🟨 Interventions:

• Educate parents to avoid scolding or punishment
• Encourage routine nail trimming and hygiene
• Apply bitter-tasting nail solutions (under pediatric guidance)
• Introduce relaxation activities (drawing, music)
• Support positive parenting practices – praise over punishment
• Provide group therapy/play therapy if needed

---

🚨 Complications (If persistent and untreated):

❌ Nail infections (bacterial/paronychia)
❌ Damage to nail matrix → abnormal nail growth
❌ Dental malocclusion or gum injury
❌ Low self-esteem and social embarrassment
❌ Link with OCD or anxiety disorders in adolescence

---

📚 Golden One-Liners for Quick Revision:

🟡 Nail biting = Common body-focused repetitive behavior (BFRB)
🟡 Habit Reversal Therapy = First-line management
🟡 Associated with stress, anxiety, and boredom
🟡 Parental support is essential; avoid scolding
🟡 May indicate underlying OCD if severe and persistent

---

✅ Top 7 MCQs for Practice:

---

Q1. Nail biting is classified under:
🅰️ Speech disorders
🅱️ Motor disorders
✅ 🅲️ Body-focused repetitive behaviors
🅳️ Sensory disorders
Correct Answer: 🅲️ Body-focused repetitive behaviors

---

Q2. Best first-line treatment for nail biting is:
🅰️ Antibiotics
🅱️ Sedation
✅ 🅲️ Behavioral therapy
🅳️ Surgery
Correct Answer: 🅲️ Behavioral therapy

---

Q3. Nail biting is commonly triggered by:
🅰️ Infection
✅ 🅱️ Stress or boredom
🅲️ Cold weather
🅳️ Allergy
Correct Answer: 🅱️ Stress or boredom

---

Q4. Persistent nail biting can lead to:
🅰️ Nail growth
🅱️ Eye infection
✅ 🅲️ Paronychia (nail bed infection)
🅳️ Vision loss
Correct Answer: 🅲️ Paronychia (nail bed infection)

---

Q5. Habit reversal technique involves:
🅰️ Physical punishment
🅱️ Sedative medications
✅ 🅲️ Replacing habit with alternative action
🅳️ Ignoring the habit
Correct Answer: 🅲️ Replacing habit with alternative action

---

Q6. Nail biting becomes a concern when:
🅰️ It occurs during sleep
🅱️ Child is under 3 years
✅ 🅲️ It leads to tissue damage or social impairment
🅳️ Nails grow longer
Correct Answer: 🅲️ It leads to tissue damage or social impairment

---

Q7. In severe cases of nail biting with anxiety, drug of choice is:
🅰️ Paracetamol
✅ 🅱️ Fluoxetine
🅲️ Diazepam
🅳️ Ciprofloxacin
Correct Answer: 🅱️ Fluoxetine

🚽🧒 Childhood Disorders – Encopresis (Fecal Incontinence)

📘 Essential for Pediatric Nursing, Mental Health Nursing, Community Health Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Encopresis is the repeated involuntary or intentional passage of feces in inappropriate places (e.g., clothes or floor) in a child aged 4 years or older, who is expected to have achieved bowel control.

✳️ Also called “functional fecal incontinence”, especially when not caused by any organic disease.

---

🧭 Classification:

Type	Description	Features
🟦 Primary Encopresis	Child never achieved bowel control	Starts early; may co-exist with toilet training issues
🟨 Secondary Encopresis	Child was previously continent	Often triggered by stress, constipation, or trauma
🟩 With Constipation and Overflow	Most common; stools leak around impacted feces	Hard stools, abdominal pain, soiling without awareness
🟥 Without Constipation	Often psychological or behavioral	Intentional defecation in wrong places; oppositional behavior

---

🧠 Causes and Risk Factors:

🟩 Physical Causes:

• Chronic constipation
• Painful defecation → stool withholding
• Low-fiber diet
• Anorectal malformations (rare)

🟥 Psychological Causes:

• Toilet training issues
• Family stress or neglect
• Abuse or trauma
• School avoidance

🟨 Associated Conditions:

• ADHD
• Oppositional defiant disorder (ODD)
• Autism spectrum disorders
• Depression/anxiety

---

⚠️ Clinical Features:

Area	Observations
💩 Stool	Infrequent large stools, fecal smearing, leakage in underwear
🤢 GI	Abdominal pain, bloating, poor appetite
🧠 Emotional	Embarrassment, low self-esteem, social withdrawal
🧪 Behavior	Stool-hiding, resisting toilet use, soiling during the day

---

🔬 Diagnostic Evaluation:

• History & Physical Exam
• Abdominal X-ray – check for fecal impaction
• Anorectal manometry (if refractory)
• Urinalysis – rule out UTI (may co-exist)
• Behavioral screening – ADHD, ODD

Diagnosis is clinical and based on DSM-5 criteria:
🟡 At least 1 event/month for 3 months in a child ≥ 4 years.

---

💊 Medical Management:

✅ 1. Bowel Evacuation (Disimpaction):

• Oral polyethylene glycol (PEG)
• Lactulose or senna
• Sometimes enema (only under supervision)

✅ 2. Maintenance Therapy:

• Long-term stool softeners (e.g., lactulose)
• High-fiber diet + fluids
• Daily toilet sitting (10–15 mins after meals)

✅ 3. Behavioral Modification:

• Positive reinforcement for using toilet
• Scheduled toilet times
• Star charts/reward systems
• Avoid punishment or shame

✅ 4. Psychological Counseling:

• Cognitive-behavioral therapy (CBT)
• Family therapy if dysfunctional parenting
• Address any abuse, anxiety, or school-related stress

---

👩‍⚕️ Nursing Management:

🟩 Assessment:

• Detailed history of bowel pattern, diet, toilet training
• Observe emotional state, school performance
• Evaluate parent-child dynamics

🟨 Interventions:

• Educate caregivers about non-punitive approach
• Promote high-fiber diet and hydration
• Assist in scheduled toilet training
• Offer emotional support and reassurance
• Collaborate with pediatrician and psychologist

---

🚨 Complications (If untreated):

❌ Chronic constipation
❌ Megacolon
❌ Psychosocial issues (teasing, isolation)
❌ UTI due to rectal pressure
❌ Delayed development or academic problems

---

📚 Golden One-Liners for Quick Revision:

🟡 Encopresis = fecal soiling in children ≥ 4 years
🟡 Most cases due to chronic constipation with overflow
🟡 Treatment = disimpaction, dietary change, behavior therapy
🟡 Avoid blaming or punishing the child
🟡 Positive reinforcement and regular toilet timing are key

---

✅ Top 7 MCQs for Practice:

---

Q1. Encopresis is defined as:
🅰️ Urine leakage in sleep
✅ 🅱️ Repeated inappropriate defecation in child ≥ 4 years
🅲️ Diarrhea
🅳️ Delayed language
Correct Answer: 🅱️ Repeated inappropriate defecation in child ≥ 4 years

---

Q2. Most common type of encopresis is:
🅰️ Without constipation
✅ 🅱️ With constipation and overflow
🅲️ Night-only soiling
🅳️ Seizure-related
Correct Answer: 🅱️ With constipation and overflow

---

Q3. Encopresis is diagnosed when soiling occurs at least:
🅰️ Once in 1 month for 1 month
🅱️ Twice in 2 months
✅ 🅲️ Once a month for 3 months
🅳️ Daily for 1 week
Correct Answer: 🅲️ Once a month for 3 months

---

Q4. Which medication is used for disimpaction in encopresis?
🅰️ Omeprazole
🅱️ Paracetamol
✅ 🅲️ Polyethylene glycol (PEG)
🅳️ Diazepam
Correct Answer: 🅲️ Polyethylene glycol (PEG)

---

Q5. Nursing intervention in encopresis includes:
🅰️ Scolding the child
🅱️ Limiting fiber
✅ 🅲️ Positive toilet training and fiber-rich diet
🅳️ Avoiding liquids
Correct Answer: 🅲️ Positive toilet training and fiber-rich diet

---

Q6. Emotional complication of encopresis may include:
🅰️ Excitement
✅ 🅱️ Low self-esteem
🅲️ Memory loss
🅳️ Hyperactivity
Correct Answer: 🅱️ Low self-esteem

---

Q7. The age criterion for encopresis diagnosis is:
🅰️ ≥ 2 years
🅱️ ≥ 3 years
✅ 🅲️ ≥ 4 years
🅳️ ≥ 6 years
Correct Answer: 🅲️ ≥ 4 years

👍👶 Childhood Behavioral Issue – Thumb Sucking

📘 Important for Pediatric Nursing, Mental Health Nursing, Growth & Development, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Thumb sucking is a non-nutritive sucking behavior commonly seen in infants and toddlers, where the child repeatedly sucks on their thumb or fingers, often as a form of self-soothing or comfort.

✳️ It is a normal developmental behavior up to 3–4 years of age but becomes a concern if it persists beyond 5 years, especially if associated with dental or psychological issues.

---

🧭 Types of Thumb Sucking:

Type	Description	Significance
🟩 Normal	Occurs occasionally in infants & toddlers	Self-soothing; not harmful
🟨 Habitual	Persistent and repeated, especially during sleep	Risk of dental malalignment
🟥 Pathological	Continues beyond 5–6 years or causes physical/emotional issues	May indicate stress, anxiety, or developmental delay

---

🧠 Causes & Contributing Factors:

🔹 Natural reflex in infancy
🔹 Boredom or inactivity
🔹 Emotional insecurity or lack of attention
🔹 Fatigue or sleepiness
🔹 Hunger
🔹 Separation from caregiver
🔹 Sibling rivalry or stress

---

⚠️ Risk Factors:

🔸 First-born child
🔸 Prolonged bottle-feeding
🔸 Lack of parental bonding
🔸 Strict or punitive parenting
🔸 Premature or low-birth-weight infants

---

📌 Clinical Features:

Feature	Observation
👄 Oral	Redness of thumb, callus, chapped skin
🦷 Dental	Overbite (protruding upper teeth), open bite, malocclusion
🧠 Behavioral	Habitual sucking during stress, sleep, boredom
✋ Hand	Deformed thumbnail, recurrent infections, skin breakdown

---

⏳ Developmental Timeline:

🟩 < 2 years: Normal and self-comforting
🟨 3–4 years: May start to reduce gradually
🟥 > 5 years: Should be addressed; may impact dental and psychological health

---

🧪 Assessment & Evaluation:

• Frequency and duration of thumb sucking
• Emotional triggers (e.g., bedtime, scolding)
• Dental evaluation (if prolonged habit)
• Behavioral screening for anxiety or developmental delays
• Parent-child relationship observation

---

💊 Management Strategies:

✅ Behavioral Techniques:

• Positive reinforcement: praise for not sucking
• Distraction techniques: toys, stories, games
• Thumb guard or bandage: reminder, not punishment
• Star chart / reward system: visual motivation
• Limit triggering situations: reduce stress, boredom

✅ Parental Guidance:

• Avoid scolding or shaming the child
• Offer attention and affection
• Consistent bedtime routine
• Address emotional insecurity

✅ If Habit Persists (>5 years):

• Dental referral for malocclusion
• Psychological counseling if linked to emotional distress
• Mild bitter-tasting preparations (on thumb) – under supervision

---

👩‍⚕️ Nursing Management:

🟩 Assessment:

• Duration, frequency, and pattern
• Emotional or behavioral concerns
• Physical impact on oral cavity and thumb

🟨 Intervention:

• Educate parents about normal age limits
• Encourage non-judgmental parenting
• Suggest behavioral distraction techniques
• Recommend dental check-up if needed
• Refer for play therapy or child psychologist if unresolved

---

🚨 Complications (if persistent beyond age 5–6):

❌ Dental malocclusion
❌ Speech delay or lisping
❌ Thumb deformity or infection
❌ Low self-esteem due to peer teasing
❌ Social withdrawal

---

📚 Golden One-Liners for Quick Revision:

🟡 Thumb sucking is normal up to 3–4 years
🟡 Persistent thumb sucking → dental issues and psychosocial impact
🟡 First-line management = behavioral modification and positive reinforcement
🟡 Avoid punishment; use thumb guards or reward charts
🟡 Referral needed if habit persists beyond 5–6 years

---

✅ Top 7 MCQs for Practice:

---

Q1. Thumb sucking is considered normal up to which age?
🅰️ 1 year
🅱️ 2 years
✅ 🅲️ 3–4 years
🅳️ 6 years
Correct Answer: 🅲️ 3–4 years

---

Q2. Most effective first-line approach for thumb sucking is:
🅰️ Physical punishment
🅱️ Sedation
✅ 🅲️ Behavioral therapy and reinforcement
🅳️ Surgery
Correct Answer: 🅲️ Behavioral therapy and reinforcement

---

Q3. A dental complication of prolonged thumb sucking is:
🅰️ Caries
🅱️ Gingivitis
✅ 🅲️ Overbite (malocclusion)
🅳️ Bruxism
Correct Answer: 🅲️ Overbite (malocclusion)

---

Q4. Which of the following is a safe behavioral intervention?
🅰️ Apply hot oil
🅱️ Tie child’s hands
✅ 🅲️ Use of thumb guard and star chart
🅳️ Scolding regularly
Correct Answer: 🅲️ Use of thumb guard and star chart

---

Q5. Persistent thumb sucking may indicate:
🅰️ Normal growth
✅ 🅱️ Emotional insecurity or anxiety
🅲️ Teething
🅳️ Nail growth issues
Correct Answer: 🅱️ Emotional insecurity or anxiety

---

Q6. Which technique is useful to monitor progress in habit reversal?
🅰️ Bedrest
🅱️ Sugar cubes
✅ 🅲️ Reward/star chart
🅳️ Bitter food
Correct Answer: 🅲️ Reward/star chart

---

Q7. Thumb sucking after age 5 requires:
🅰️ No intervention
✅ 🅱️ Dental or psychological referral
🅲️ Antibiotics
🅳️ Forceful training
Correct Answer: 🅱️ Dental or psychological referral

🛌🚶‍♂️ Childhood Disorders – Somnambulism (Sleepwalking)

📘 Important for Pediatric Nursing, Mental Health Nursing, Community Health, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Somnambulism, commonly known as sleepwalking, is a non-REM parasomnia in which a child walks or performs complex activities while still asleep, typically occurring during deep sleep (stage 3 NREM) in the first third of the night.

✳️ The child appears awake but is unaware and unresponsive, and does not remember the event after waking.

---

🧭 Key Characteristics:

Feature	Observation
😴 Sleep Phase	Occurs during slow-wave (deep) NREM sleep
⏰ Timing	Commonly during the first few hours after sleep onset
🧒 Age	Most common in 4–12 years
🧠 Memory	No recollection of the episode the next day
⚠️ Safety	May involve risky behaviors like walking, opening doors, stairs

---

🧠 Etiology / Causes:

🟩 Biological Triggers:

• Immature central nervous system
• Genetic predisposition (family history)
• Sleep deprivation
• Fever or illness

🟥 Environmental / Psychological Triggers:

• Stress or anxiety
• Disruption in sleep routine
• Noisy sleep environment
• Sleep apnea or other sleep disorders

---

⚠️ Risk Factors:

🔹 Age 4–12 years
🔹 Sleep deprivation
🔹 Irregular sleep schedules
🔹 Emotional stress
🔹 Family history of sleepwalking
🔹 Use of sedatives or antihistamines

---

📌 Clinical Features:

Stage	Signs
🟩 During Episode	Sitting up, walking, opening doors, talking, staring blankly
🟨 Behavior	Confused if awakened, hard to arouse
🟥 After Episode	Returns to sleep without awareness; amnesia about the event
🚨 Severe	Wandering outdoors, risk of falls or injuries

---

🧪 Diagnostic Evaluation:

• Sleep history from caregivers
• Sleep diary or video documentation
• Polysomnography (sleep study) – if episodes are frequent or dangerous
• Rule out epilepsy or night terrors

Somnambulism is typically diagnosed clinically.

---

💊 Medical Management:

✅ Non-Pharmacological (First Line):

• Establish consistent bedtime routine
• Ensure adequate sleep duration
• Maintain a safe sleeping environment (lock doors/windows)
• Minimize stress and screen time before bed
• Use of bed alarms or door chimes if risk of wandering

✅ Pharmacological (Rare & Only if Severe):

• Clonazepam (low-dose)
• Melatonin (in case of disrupted sleep cycles)

---

👩‍⚕️ Nursing Management:

🟩 Assessment:

• Observe and document frequency, duration, and activity during episodes
• Rule out seizure disorder
• Assess family stress and bedtime routines

🟨 Interventions:

• Educate caregivers: don’t wake the child during an episode
• Gently guide child back to bed
• Remove sharp or dangerous objects from the bedroom
• Install door locks or alarms for safety
• Provide psychological support if related to anxiety/stress

🟥 Parent Teaching:

• Condition is self-limiting and often resolves with age
• Avoid scolding or labeling the child
• Encourage calm, consistent nighttime rituals
• Use of white noise or soft music may help sleep stability

---

🚨 Complications (if unmanaged):

❌ Injuries (fall, stairs, sharp objects)
❌ Emotional distress in family
❌ Daytime sleepiness
❌ Academic decline due to poor sleep
❌ Rarely, co-occurring sleep disorders (e.g., night terrors)

---

📚 Golden One-Liners for Quick Revision:

🟡 Somnambulism = Sleepwalking during deep NREM sleep
🟡 Common in 4–12 years, often resolves by adolescence
🟡 Child has no memory of the episode
🟡 Management: routine + safety + support
🟡 Avoid waking child during episode; ensure safe environment

---

✅ Top 7 MCQs for Practice:

---

Q1. Somnambulism most commonly occurs during:
🅰️ REM sleep
✅ 🅱️ Stage 3 NREM sleep
🅲️ While awake
🅳️ Just before waking
Correct Answer: 🅱️ Stage 3 NREM sleep

---

Q2. Typical age group for somnambulism is:
🅰️ 1–3 years
✅ 🅱️ 4–12 years
🅲️ Teenagers only
🅳️ Adults >30
Correct Answer: 🅱️ 4–12 years

---

Q3. Somnambulism is best described as:
🅰️ Night terror
🅱️ Sleep talking
✅ 🅲️ Sleepwalking with no recall
🅳️ Daydreaming
Correct Answer: 🅲️ Sleepwalking with no recall

---

Q4. What should a nurse do during a sleepwalking episode?
🅰️ Wake the child forcefully
✅ 🅱️ Gently guide child back to bed
🅲️ Shake the child
🅳️ Lock the door with child inside
Correct Answer: 🅱️ Gently guide child back to bed

---

Q5. Which medication is used only in severe sleepwalking cases?
🅰️ Paracetamol
🅱️ Risperidone
✅ 🅲️ Clonazepam
🅳️ Ibuprofen
Correct Answer: 🅲️ Clonazepam

---

Q6. Which of the following is true about somnambulism?
🅰️ Always indicates epilepsy
🅱️ Happens during dreaming
✅ 🅲️ Often resolves as the child grows
🅳️ Requires surgery
Correct Answer: 🅲️ Often resolves as the child grows

---

Q7. Key nursing goal in somnambulism is to:
🅰️ Train the child to wake up
🅱️ Scold the child
✅ 🅲️ Ensure safety and sleep hygiene
🅳️ Use restraints
Correct Answer: 🅲️ Ensure safety and sleep hygiene

🍛⚖️ Childhood Disorders – Protein Energy Malnutrition (PEM)

📘 Essential for Pediatric Nursing, Community Health Nursing, Nutrition, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Protein Energy Malnutrition (PEM) is a range of clinical disorders in children caused by inadequate intake of protein and calories, resulting in underweight, stunting, wasting, and in severe cases, life-threatening illness.

✳️ PEM is most prevalent in children under 5 years, especially in developing countries.

---

🧭 Classification of PEM (by WHO & IAP):

🟥 1. WHO Classification:

Type	Criteria
🟨 Underweight	Low weight for age
🟩 Wasting	Low weight for height (acute malnutrition)
🟦 Stunting	Low height for age (chronic malnutrition)

🟥 2. Indian Academy of Pediatrics (IAP) – Gomez Classification:

Degree	% of Expected Weight for Age
🟩 Grade I (Mild)	71–80%
🟨 Grade II (Moderate)	61–70%
🟥 Grade III (Severe)	51–60%
🟦 Grade IV (Very Severe)	< 50%

---

🧠 Types of Severe PEM:

Condition	Key Features
🟥 Marasmus	Severe wasting due to deficiency of both protein & calories
🟨 Kwashiorkor	Edematous malnutrition due to protein deficiency only, with some calories present
🟩 Marasmic-Kwashiorkor	Combined features of both

---

⚠️ Causes of PEM:

🟩 Primary Causes:

• Inadequate food intake (quantity/quality)
• Improper breastfeeding and weaning
• Poverty and food insecurity

🟥 Secondary Causes:

• Infections (measles, TB, diarrhea)
• Malabsorption syndromes
• Chronic illnesses
• Parental ignorance

---

📌 Risk Factors:

🔸 Age < 5 years
🔸 Low birth weight
🔸 Repeated infections
🔸 Early or delayed weaning
🔸 Poor sanitation and hygiene
🔸 Illiterate or neglectful caregivers

---

📉 Clinical Features:

Feature	Marasmus	Kwashiorkor
🩻 Weight	Severely low	Moderate to low
💪 Muscles	Wasted	Not always wasted
💧 Edema	Absent	Present (esp. legs, face)
😐 Face	Monkey-like	Moon face
🍌 Skin	Dry, wrinkled	Flaky paint dermatosis
💇 Hair	Sparse	Easily pluckable, discolored
🗣️ Behavior	Alert, irritable	Apathetic, poor appetite
⚠️ Others	Severe wasting	Fatty liver, anemia

---

🧪 Diagnostic Evaluation:

• Anthropometric Measurements:
  • Weight-for-age, Height-for-age, Weight-for-height
  • Mid-upper arm circumference (MUAC <11.5 cm = SAM)
• Laboratory Investigations:
  • Hemoglobin (↓), serum albumin (↓ in Kwashiorkor)
  • Blood glucose, electrolytes
  • Stool examination (for parasites)
  • Chest X-ray (if infection suspected)

---

💊 Management of PEM (as per IMNCI & WHO guidelines):

✅ 1. Stabilization Phase (first 7 days):

• Treat/prevent hypoglycemia, hypothermia, dehydration, infection
• Provide micronutrients (Vitamin A, folic acid, zinc)
• Therapeutic milk (F-75) – low-protein, low-calorie starter formula

✅ 2. Transition Phase:

• Switch to F-100 milk (high protein, high calorie)
• Gradually increase energy and protein

✅ 3. Rehabilitation Phase:

• Start catch-up growth feeding
• Continue breastfeeding
• Stimulate play & interaction
• Treat underlying illnesses

---

👩‍⚕️ Nursing Management:

🟩 Assessment:

• Daily weight, MUAC, input-output
• Watch for signs of infection and dehydration
• Monitor edema, skin condition, and feeding tolerance

🟨 Interventions:

• Ensure proper feeding technique
• Educate caregivers about nutrition and hygiene
• Prevent cross-infection in hospital
• Provide emotional and sensory stimulation (play, touch)
• Support exclusive breastfeeding & timely complementary feeding

---

🚨 Complications:

❌ Hypoglycemia
❌ Hypothermia
❌ Infections (diarrhea, pneumonia)
❌ Dehydration
❌ Electrolyte imbalance
❌ Vitamin/mineral deficiency
❌ Delayed development and learning disability

---

📚 Golden One-Liners for Quick Revision:

🟡 Marasmus = energy + protein deficiency → severe wasting
🟡 Kwashiorkor = protein deficiency → edema + fatty liver
🟡 F-75 & F-100 = therapeutic feeds used in PEM
🟡 MUAC < 11.5 cm = Severe Acute Malnutrition (SAM)
🟡 Treat infections, give micronutrients, start feeding gently

---

✅ Top 7 MCQs for Practice:

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Q1. MUAC value indicating severe acute malnutrition is:
🅰️ > 13.5 cm
🅱️ 12.5–13.5 cm
✅ 🅲️ < 11.5 cm
🅳️ < 10 cm
Correct Answer: 🅲️ < 11.5 cm

---

Q2. Moon face and edema are features of:
🅰️ Marasmus
✅ 🅱️ Kwashiorkor
🅲️ Rickets
🅳️ Scurvy
Correct Answer: 🅱️ Kwashiorkor

---

Q3. F-75 formula is used in which phase of PEM management?
🅰️ Rehabilitation
✅ 🅱️ Stabilization
🅲️ Maintenance
🅳️ Terminal
Correct Answer: 🅱️ Stabilization

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Q4. Which sign is most specific to Marasmus?
🅰️ Edema
🅱️ Moon face
✅ 🅲️ Severe wasting without edema
🅳️ Flaky skin
Correct Answer: 🅲️ Severe wasting without edema

---

Q5. Therapeutic feeding in rehabilitation uses:
🅰️ ORS
🅱️ F-75
✅ 🅲️ F-100
🅳️ Cow’s milk
Correct Answer: 🅲️ F-100

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Q6. Main cause of death in untreated PEM is:
🅰️ Overfeeding
✅ 🅱️ Infections and electrolyte imbalance
🅲️ Liver failure
🅳️ Vitamin toxicity
Correct Answer: 🅱️ Infections and electrolyte imbalance

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Q7. Common skin change in kwashiorkor:
🅰️ Cracked lips
🅱️ Pale patches
✅ 🅲️ Flaky paint dermatosis
🅳️ Hyperpigmentation
Correct Answer: 🅲️ Flaky paint dermatosis

🪱👶 Childhood Disorders – Helminthic Infections (Worm Infestation)

📘 Important for Pediatric Nursing, Community Health, Infectious Disease Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Helminthic infections refer to parasitic worm infestations in humans, commonly affecting the gastrointestinal tract of children, leading to nutritional deficiencies, anemia, growth retardation, and other systemic effects.

✳️ These infections are more common in low-resource settings, poor hygiene, and in school-age children.

---

🧭 Types of Helminths (Worms):

Type	Example	Habitat
🟩 Roundworms (Nematodes)	Ascaris lumbricoides	Small intestine
🟨 Hookworms	Ancylostoma duodenale, Necator americanus	Intestinal wall
🟥 Whipworms	Trichuris trichiura	Large intestine
🟦 Pinworms (Threadworms)	Enterobius vermicularis	Rectum & anal region
🟪 Tapeworms (Cestodes)	Taenia saginata, Taenia solium	Intestine
🟫 Flukes (Trematodes)	Schistosoma species	Bloodstream, bladder, liver

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🧠 Causes & Transmission:

🔹 Poor hand hygiene
🔹 Eating contaminated food or unwashed vegetables
🔹 Drinking contaminated water
🔹 Walking barefoot on infected soil
🔹 Close contact with infected individuals (especially in pinworms)

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⚠️ Risk Factors in Children:

🔸 Poor sanitation and open defecation
🔸 Barefoot walking
🔸 Malnutrition
🔸 Low socioeconomic status
🔸 School attendance in endemic areas
🔸 Playing in contaminated soil

---

📌 Clinical Features:

Worm Type	Common Symptoms
🟩 Ascaris	Abdominal pain, nausea, growth retardation, intestinal obstruction
🟨 Hookworm	Iron deficiency anemia, fatigue, pale skin
🟥 Whipworm	Chronic diarrhea, rectal prolapse
🟦 Pinworm	Perianal itching (especially at night), disturbed sleep
🟪 Tapeworm	Abdominal pain, weight loss, presence of segments in stool
🟫 Flukes	Urinary symptoms, hepatosplenomegaly (Schistosoma)

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🧪 Diagnosis:

• Stool examination – Ova or larvae detection (most common)
• Perianal swab or cellophane tape test – For pinworm
• CBC – Eosinophilia
• Serologic tests – For tissue-invasive species
• Imaging (X-ray/USG) – If complications (intestinal obstruction, liver cysts)

---

💊 Medical Management (Deworming):

✅ First-Line Anthelmintics:

Drug	Dose	Effective Against
Albendazole	400 mg single dose (>2 yrs)	Roundworm, hookworm, whipworm, pinworm
Mebendazole	100 mg twice daily × 3 days	Same as above
Pyrantel pamoate	10 mg/kg single dose	Pinworm, roundworm
Praziquantel	As per weight	Tapeworms, flukes
Niclosamide	For tapeworms	Taenia saginata, solium

Repeat dose may be needed after 2 weeks for pinworms.

---

🧑‍⚕️ Nursing Management:

🟩 Assessment:

• Nutritional status, anemia, weight loss
• Abdominal tenderness, bloating
• Perianal itching or scratching marks
• History of hygiene practices, barefoot walking

🟨 Interventions:

• Administer deworming drugs as prescribed
• Teach handwashing before meals & after toilet
• Promote use of footwear outdoors
• Recommend clean drinking water & properly washed vegetables
• Educate on avoiding open defecation
• Follow up on treatment completion & family screening

---

🚨 Complications:

❌ Intestinal obstruction (esp. by Ascaris)
❌ Severe anemia (hookworm)
❌ Malnutrition and growth failure
❌ Appendicitis (rare)
❌ Rectal prolapse (whipworm)
❌ Seizures (neurocysticercosis by Taenia solium)

---

📚 Golden One-Liners for Quick Revision:

🟡 Albendazole = first-line treatment for most helminths
🟡 Pinworm = causes nighttime perianal itching
🟡 Hookworm = leads to iron-deficiency anemia
🟡 Deworming is recommended twice yearly in endemic areas
🟡 Hygiene and sanitation are key to prevention

---

✅ Top 7 MCQs for Practice:

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Q1. Which helminth causes perianal itching at night?
🅰️ Ascaris
🅱️ Hookworm
✅ 🅲️ Enterobius vermicularis (Pinworm)
🅳️ Whipworm
Correct Answer: 🅲️ Enterobius vermicularis

---

Q2. Drug of choice for mass deworming in children is:
🅰️ Metronidazole
✅ 🅱️ Albendazole
🅲️ Praziquantel
🅳️ Ciprofloxacin
Correct Answer: 🅱️ Albendazole

---

Q3. Common complication of hookworm infestation is:
🅰️ Constipation
✅ 🅱️ Iron-deficiency anemia
🅲️ Liver abscess
🅳️ Perianal itching
Correct Answer: 🅱️ Iron-deficiency anemia

---

Q4. Which test is used for detecting pinworms?
🅰️ Stool culture
🅱️ CBC
✅ 🅲️ Cellophane tape test
🅳️ Mantoux
Correct Answer: 🅲️ Cellophane tape test

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Q5. Which worm is known to cause intestinal obstruction in children?
🅰️ Hookworm
✅ 🅱️ Ascaris lumbricoides
🅲️ Pinworm
🅳️ Tapeworm
Correct Answer: 🅱️ Ascaris lumbricoides

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Q6. Whipworm (Trichuris) commonly causes:
🅰️ Jaundice
🅱️ Constipation
✅ 🅲️ Rectal prolapse and diarrhea
🅳️ Cough
Correct Answer: 🅲️ Rectal prolapse and diarrhea

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Q7. Recommended age to start deworming in national programs:
🅰️ 1 month
🅱️ 6 months
✅ 🅲️ 1 year and above
🅳️ 10 years
Correct Answer: 🅲️ 1 year and above

🐍🦟 Childhood Emergencies – Bites and Stings

📘 Important for Pediatric Nursing, Emergency Nursing, Community Health, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Bites and stings are injuries caused by the teeth or venomous apparatus (fangs, stingers) of animals, insects, or humans. These are common in children due to their outdoor activities, curiosity, and thin skin, making them more vulnerable to envenomation, allergic reactions, and infections.

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🧭 Types of Bites and Stings:

Category	Examples
🐍 Snake Bites	Cobra, Viper, Krait
🦟 Insect Stings	Bee, Wasp, Hornet
🕷️ Arthropod Bites	Spider, Scorpion, Tick
🐶 Animal Bites	Dog, Cat, Monkey (Rabies concern)
👦 Human Bites	During fights or seizures

---

🧠 Common Toxins & Reactions:

Source	Effect
🐍 Snake venom	Neurotoxic (paralysis), hemotoxic (bleeding), cytotoxic (tissue necrosis)
🦂 Scorpion venom	Autonomic storm: sweating, hypertension, shock
🐝 Bee/wasp venom	Allergic reactions, local swelling, anaphylaxis
🕷️ Spider	Muscle cramps, necrosis (some species)
🐶 Animal bite saliva	Rabies virus risk, secondary bacterial infection

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📌 General Clinical Features:

Local Reaction	Systemic Reaction
Redness, swelling, pain, warmth	Fever, malaise, hypotension
Bleeding, bruising	Anaphylaxis (insect stings)
Fang/sting marks	Neurotoxicity: ptosis, paralysis (snakes)
Tissue necrosis	Hemorrhage (viper bites)
Urticaria (hives)	Seizures (scorpion, snake)

---

🧪 Diagnostic Evaluation (As Needed):

• 20-minute whole blood clotting test (WBCT) – for snakebite
• CBC, coagulation profile – hemotoxic bites
• Serum electrolytes, ECG – in scorpion or spider bite
• Allergy testing – recurrent insect sting reactions
• Wound swab & culture – in infected animal/human bites
• Rabies risk assessment – for dog/cat/monkey bites

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💉 Medical & Emergency Management:

✅ Snake Bite (First Aid & Treatment):

• Reassure the child and immobilize the limb
• Do not suck, cut, or apply tourniquet
• Transport to hospital urgently
• Anti-snake venom (ASV) administration as per type and severity
• Tetanus toxoid, antibiotics, supportive care

✅ Scorpion Sting:

• Clean site, apply cold compress
• Prazosin is the drug of choice
• Monitor vitals, manage cardiac or respiratory symptoms

✅ Insect Stings (Bee, Wasp):

• Remove stinger by scraping
• Wash area, apply cold pack
• Administer antihistamines and analgesics
• Adrenaline IM (0.01 mg/kg) in anaphylaxis
• Oxygen, IV fluids, corticosteroids if needed

✅ Dog/Animal Bites:

• Immediate washing with soap and running water × 15 mins
• Tetanus prophylaxis
• Anti-rabies vaccine (ARV) + Rabies immunoglobulin (RIG) if indicated (Category III bite)
• Oral antibiotics (Amoxicillin + clavulanic acid)

✅ Human Bites:

• Wash thoroughly, antiseptic dressing
• Tetanus prophylaxis
• Antibiotics
• Assess for HIV/Hepatitis B exposure if deep bite

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👩‍⚕️ Nursing Management:

🟩 Assessment:

• Identify source (snake, bee, dog, etc.)
• Note time and site of bite
• Check for fang marks, swelling, signs of systemic envenomation
• Monitor for allergic reactions

🟨 Interventions:

• Keep the child calm and the bite area immobile
• Administer prescribed antivenom or antibiotics
• Watch for signs of anaphylaxis
• Maintain airway, breathing, circulation (ABC)
• Document type of bite/sting, site, treatment given

🟥 Health Education:

• Avoid barefoot walking in rural areas
• Safe play areas, insect repellents, mosquito nets
• Immediate medical help for bites/stings
• Rabies awareness and pet vaccination

---

🚨 Complications:

❌ Anaphylaxis
❌ Cellulitis, abscess
❌ Rabies
❌ Sepsis
❌ Gangrene or tissue loss
❌ Neurological damage (e.g., respiratory failure in neurotoxic snake bite)

---

📚 Golden One-Liners for Quick Revision:

🟡 Snakebite = don’t cut, suck, or tourniquet; give ASV
🟡 Rabies = 100% fatal but preventable with timely vaccine
🟡 Bee sting = anaphylaxis → treat with adrenaline
🟡 Scorpion sting = prazosin is drug of choice
🟡 Dog bite (Category III) = ARV + RIG + TT

---

✅ Top 7 MCQs for Practice:

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Q1. First aid for snake bite includes:
🅰️ Applying tourniquet
✅ 🅱️ Immobilizing the limb
🅲️ Sucking venom
🅳️ Incising the wound
Correct Answer: 🅱️ Immobilizing the limb

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Q2. Which drug is used in scorpion sting management?
🅰️ Atropine
✅ 🅱️ Prazosin
🅲️ Adrenaline
🅳️ Diazepam
Correct Answer: 🅱️ Prazosin

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Q3. A child develops perianal itching at night; likely cause is:
🅰️ Whipworm
🅱️ Tapeworm
✅ 🅲️ Pinworm
🅳️ Ascaris
Correct Answer: 🅲️ Pinworm

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Q4. Dog bite Category III management includes:
🅰️ Only soap wash
🅱️ Tetanus only
✅ 🅲️ ARV + RIG + TT
🅳️ Antibiotics only
Correct Answer: 🅲️ ARV + RIG + TT

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Q5. Which of the following bites can cause paralysis?
🅰️ Bee sting
🅱️ Spider bite
✅ 🅲️ Snakebite (neurotoxic)
🅳️ Mosquito bite
Correct Answer: 🅲️ Snakebite (neurotoxic)

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Q6. Best way to remove bee sting is:
🅰️ With fingers
✅ 🅱️ Scrape gently with blunt object
🅲️ Burn it
🅳️ Vacuum it out
Correct Answer: 🅱️ Scrape gently with blunt object

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Q7. Common complication of untreated dog bite is:
🅰️ Dengue
🅱️ Seizures
✅ 🅲️ Rabies
🅳️ Malaria
Correct Answer: 🅲️ Rabies

🧱👧 Childhood Behavioral Disorder – Pica

📘 Important for Pediatric Nursing, Mental Health Nursing, Growth & Development, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Pica is a persistent eating of non-nutritive, non-food substances for at least 1 month, which is developmentally inappropriate and not part of a culturally accepted practice.

✳️ Commonly seen in toddlers, preschoolers, children with intellectual disabilities, and in nutritional deficiencies.

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🧭 Common Non-Food Substances Eaten in Pica:

Substance	Name
🧱 Clay/soil	Geophagia
❄️ Ice	Pagophagia
🧼 Soap, chalk	Miscellaneous pica
📰 Paper	Xylophagia
🍂 Hair	Trichophagia
🧲 Metal, pins	Metallophagia

---

🧠 Causes / Risk Factors:

🟩 Biological Causes:

• Iron deficiency anemia
• Zinc deficiency
• Malnutrition or hunger

🟥 Psychological Causes:

• Mental retardation
• Autism spectrum disorders
• Emotional deprivation or neglect
• Family conflict or trauma

🟨 Environmental/Social Factors:

• Poverty
• Parental ignorance
• Unsupervised children
• Cultural or ritual practices (rare)

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⚠️ Age Criteria (DSM-5):

• Pica is only diagnosed in children >2 years, as mouthing behavior is normal in infants

---

📌 Clinical Features:

Category	Signs
🍽️ Eating Behavior	Persistent craving for non-food substances for >1 month
🧠 Psychological	Restlessness, irritability, attention-seeking behavior
⚠️ Physical Complications	Abdominal pain, constipation, diarrhea, lead poisoning (paint), parasitic infections
🩸 Nutritional	Iron deficiency anemia, weight loss, malnutrition

---

🧪 Diagnostic Evaluation:

• Clinical history of eating non-food items
• CBC – check for anemia
• Serum iron, zinc, calcium levels
• Stool exam – ova/parasites if geophagia
• X-ray abdomen – in case of intestinal obstruction
• Psychological assessment – to rule out developmental delay or OCD

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💊 Management of Pica:

✅ Medical Treatment:

• Treat underlying nutritional deficiencies:
  • Iron, zinc, multivitamins
• Deworming (Albendazole/Mebendazole)
• Manage complications (e.g., lead toxicity, GI block)

✅ Behavioral Therapy:

• Habit reversal therapy
• Positive reinforcement for appropriate behavior
• Cognitive-behavioral therapy (CBT) in older children
• Use of reward charts and avoidance cues

✅ Environmental Modification:

• Keep dangerous non-edible items out of reach
• Improve parent-child interaction and supervision
• Educate family about nutritional foods and safe habits

---

👩‍⚕️ Nursing Management:

🟩 Assessment:

• Ask parents about child’s eating habits
• Observe for signs of nutritional deficiency
• Assess growth and development milestones
• Evaluate home environment and parenting style

🟨 Intervention:

• Educate parents to avoid punishment
• Ensure safe home environment (remove harmful items)
• Administer supplements as prescribed
• Refer to nutritionist or psychologist if needed
• Promote healthy eating and routine

---

🚨 Complications (if untreated):

❌ Lead poisoning
❌ Intestinal obstruction or perforation
❌ Parasite infections
❌ Severe malnutrition
❌ Dental problems
❌ Developmental delay (if associated disorder)

---

📚 Golden One-Liners for Quick Revision:

🟡 Pica = persistent eating of non-food items for >1 month
🟡 Common in iron deficiency, developmental delay
🟡 Clay eating = Geophagia, ice eating = Pagophagia
🟡 Risk of lead poisoning, worm infestation
🟡 Treat deficiency + behavior modification = key management

---

✅ Top 7 MCQs for Practice:

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Q1. Pica is the eating of:
🅰️ Junk food
✅ 🅱️ Non-nutritive, non-food substances
🅲️ Spicy food
🅳️ Excess fruits
Correct Answer: 🅱️ Non-nutritive, non-food substances

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Q2. Eating clay is termed as:
🅰️ Pagophagia
🅱️ Trichophagia
✅ 🅲️ Geophagia
🅳️ Xylophagia
Correct Answer: 🅲️ Geophagia

---

Q3. Most common deficiency associated with pica:
🅰️ Calcium
✅ 🅱️ Iron
🅲️ Vitamin D
🅳️ Potassium
Correct Answer: 🅱️ Iron

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Q4. Pica is diagnosed after the child is:
🅰️ <1 year
🅱️ 18 months
✅ 🅲️ >2 years
🅳️ Any age
Correct Answer: 🅲️ >2 years

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Q5. Habit of eating hair is called:
🅰️ Geophagia
🅱️ Xylophagia
🅲️ Pagophagia
✅ 🅳️ Trichophagia
Correct Answer: 🅳️ Trichophagia

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Q6. One of the serious complications of pica is:
🅰️ Rickets
✅ 🅱️ Lead poisoning
🅲️ Asthma
🅳️ Bedwetting
Correct Answer: 🅱️ Lead poisoning

---

Q7. Management of pica includes all except:
🅰️ Nutritional correction
🅱️ Family education
✅ 🅲️ Physical punishment
🅳️ Behavioral therapy
Correct Answer: 🅲️ Physical punishment

🤸‍♂️🧒 Childhood Neurobehavioral Disorder – Tics

📘 Important for Pediatric Nursing, Mental Health Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Tics are sudden, rapid, recurrent, non-rhythmic movements or vocalizations, that are involuntary or semi-voluntary, often worsened by stress and suppressed with effort.

✳️ Tics are classified as motor or vocal, and can be transient or chronic.
✳️ Common in children aged 5–12 years, more frequent in boys.

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🧭 Classification of Tics (DSM-5):

Type	Description	Examples
🟩 Motor Tics	Sudden movement	Eye blinking, head jerking, shoulder shrugging
🟨 Vocal Tics	Involuntary sounds	Grunting, throat clearing, sniffing
🟥 Simple Tics	Short, meaningless	Eye blinking, sniffing
🟦 Complex Tics	Coordinated and patterned	Jumping, spinning, repeating words (echolalia)

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📚 Types of Tic Disorders:

Disorder	Duration	Features
🟩 Provisional Tic Disorder	<1 year	Single or multiple tics
🟨 Chronic Tic Disorder	>1 year	Motor or vocal tics (not both)
🟥 Tourette’s Syndrome	>1 year	Both motor and vocal tics present

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🧠 Causes & Risk Factors:

🟩 Neurological/Genetic:

• Family history of tics or Tourette’s syndrome
• Neurochemical imbalance (dopamine hypothesis)

🟨 Environmental/Psychological:

• Stress or anxiety
• ADHD, OCD, Autism Spectrum Disorders
• Sleep deprivation
• Certain medications (stimulants)

---

⚠️ Clinical Features:

Category	Observation
💢 Motor Tics	Eye blinking, head nodding, grimacing
🗣️ Vocal Tics	Coughing, throat clearing, barking sounds
🧠 Emotional	Embarrassment, frustration, social withdrawal
📈 Pattern	Waxing and waning; worsens with stress/excitement; less during sleep

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🧪 Diagnostic Evaluation:

• Clinical observation and history (most important)
• Use of DSM-5 criteria
• Yale Global Tic Severity Scale (YGTSS)
• Neuropsychological evaluation (if ADHD/OCD suspected)
• EEG, MRI – only if seizures or other neuro signs are present

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💊 Management of Tics:

✅ 1. Behavioral Therapy:

• Habit Reversal Training (HRT) – most effective
• CBT – especially for Tourette’s with OCD
• Relaxation techniques – breathing, yoga

✅ 2. Pharmacological Treatment (If severe):

• Clonidine/guanfacine – for mild/moderate cases
• Haloperidol, Risperidone – for severe Tourette’s
• SSRI – if co-existing OCD
• Stimulants carefully if co-existing ADHD

✅ 3. Education & Support:

• Reassure child & family – tics are common and often transient
• Avoid punishment or teasing
• Supportive schooling environment

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👩‍⚕️ Nursing Management:

🟩 Assessment:

• Onset, frequency, and type of tics
• Observe if worsened by stress or attention
• Assess for co-morbid conditions (ADHD, OCD)

🟨 Interventions:

• Provide emotional reassurance
• Educate family and teachers
• Promote stress-reduction routines
• Refer to psychologist or neurologist
• Encourage social participation and avoid isolation

---

🚨 Complications:

❌ Social embarrassment or bullying
❌ Poor academic performance
❌ Anxiety or depression
❌ Co-morbid ADHD or OCD
❌ Self-injurious behaviors (in complex tics)

---

📚 Golden One-Liners for Quick Revision:

🟡 Tics = sudden, repetitive, non-rhythmic movements/sounds
🟡 Tourette’s syndrome = both motor + vocal tics >1 year
🟡 Most tics are transient and benign
🟡 First-line therapy = Habit Reversal Training (HRT)
🟡 Haloperidol = used in severe Tourette’s cases

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✅ Top 7 MCQs for Practice:

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Q1. Which of the following is a motor tic?
🅰️ Sniffing
✅ 🅱️ Head jerking
🅲️ Grunting
🅳️ Barking
Correct Answer: 🅱️ Head jerking

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Q2. Tourette’s syndrome is diagnosed when:
🅰️ Only vocal tics are present
🅱️ Only motor tics are present
✅ 🅲️ Both motor and vocal tics >1 year
🅳️ Tics occur during sleep
Correct Answer: 🅲️ Both motor and vocal tics >1 year

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Q3. First-line behavioral therapy for tics is:
🅰️ Psychoanalysis
🅱️ Punishment
✅ 🅲️ Habit Reversal Training
🅳️ Hypnotherapy
Correct Answer: 🅲️ Habit Reversal Training

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Q4. A child with facial grimacing and throat clearing for 8 months has:
✅ 🅰️ Provisional tic disorder
🅱️ Chronic tic disorder
🅲️ OCD
🅳️ Epilepsy
Correct Answer: 🅰️ Provisional tic disorder

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Q5. Drug of choice for severe Tourette’s is:
🅰️ Fluoxetine
🅱️ Diazepam
✅ 🅲️ Haloperidol
🅳️ Paracetamol
Correct Answer: 🅲️ Haloperidol

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Q6. Tics usually disappear during:
🅰️ Fever
🅱️ Sleep
✅ 🅲️ Deep sleep
🅳️ Daytime
Correct Answer: 🅲️ Deep sleep

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Q7. One common associated disorder with tics is:
🅰️ Asthma
🅱️ Migraine
✅ 🅲️ ADHD
🅳️ Scoliosis
Correct Answer: 🅲️ ADHD