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Population Health for Nurses

26.2 Newborn, Infant, and Toddler Health

Population Health for Nurses26.2 Newborn, Infant, and Toddler Health

Learning Outcomes

By the end of this section, you should be able to:

  • 26.2.1 Assess the global and national health status of the newborn, infant, and toddler.
  • 26.2.2 Examine major risk factors influencing the health of the newborn, infant, and toddler.
  • 26.2.3 Create evidence-based educational interventions to promote self-care for health promotion, illness prevention, and illness management of newborns, infants, and toddlers.
  • 26.2.4 Identify Healthy People 2030 goals established for the newborn, infant, and toddler.
  • 26.2.5 Describe health promotion and disease prevention actions applicable to the newborn, infant, and toddler.
  • 26.2.6 Discuss evidence-based strategies for integrating sociocultural and linguistically responsive health promotion and disease prevention interventions in clinical practice of the newborn, infant, and toddler.

Newborns, infants, and toddlers (children aged 0 to 3 years) undergo rapid developmental changes in their first years of life. Addressing their health needs helps them reach critical developmental milestones, such as sitting, crawling, and walking. This age group is more susceptible to illnesses and infections than older children due to immature immune systems. Addressing their health needs can help prevent illness or its complications and ensure they receive appropriate medical care. Managing health needs early on can help prevent the later development of chronic health conditions. Additionally, when the nurse provides education that allows caregivers to feel confident in their ability to care for their child, they are better equipped to provide the necessary care and support. Finally, addressing this population’s health needs can have broader social and economic benefits. Healthy children are more likely to become healthy adults, leading to a more productive and economically stable society (Office of Child Care, n.d.; Prenatal-to-3 Policy Impact Center, 2021)

National and Global Status of Newborn, Infant, and Toddler Health

Many statistics are gathered regarding newborn, infant, and toddler health. Beyond the infant mortality rate, the United States gathers other data that illustrate the health of this population. The CDC divides data into infants and children up to age 4. According to the National Center for Health Statistics (NCHS, 2023c), in 2022, 1.5 percent of children in the United States aged 0 to 4 years were in fair or poor health, and 97.5 percent of children in the United States aged 0 to 4 years had a usual place of health care. In 2021, 3,816 deaths occurred in children aged 1 to 4 years, which is 25 deaths per 100,000 (NCHS, 2023c). The leading causes of death in this population were accidents (unintentional injuries); congenital malformations, deformations, and chromosomal abnormalities; and assault (homicide) (NCHS, 2023c).

Globally, most data are provided for children aged 0 to 5, and various other statistics are used to provide a snapshot of the health of this population. These include (World Bank Group, 2023):

  • Prevalence of anemia: 40 percent (2019)
  • Prevalence of wasting (low weight for height): 6.8 percent (2021 and 2022)
  • Prevalence of severe wasting (low weight for height more than 3 standard deviations below the median): 2.1 percent (2022)
  • Prevalence of underweight (low weight for age): 12.3 percent (2022)
  • Global mortality rate: 28 deaths per 1,000 live births (2021)
    • Males: 31 deaths per 1,000 live births
    • Females: 26 deaths per 1,000 live births

One outlier of the data collection is immunization rates, as this is reported in children aged 12 to 23 months. According to the World Bank Group (2023), 81 percent of this global population was immunized for diphtheria, pertussis, and tetanus (DPT) and 82 percent for measles in 2021.

According to the WHO (2023b), in 2018, 5.3 million children under age 5 died, nearly half of them in sub-Saharan Africa. Globally, this population’s leading causes of death are preterm birth complications, pneumonia, birth asphyxia, diarrhea, and malaria (WHO, 2023b). More than half of deaths in this age group result from preventable diseases that are treatable through simple and affordable interventions, such as vaccines and adequate nutrition, particularly early and continued breastfeeding. Nutrition-related factors contribute to about 45 percent of deaths in this population (WHO, 2023b). Data regarding immunizations and nutrition coverage worldwide can be viewed at the Maternal, Newborn, Child, and Adolescent Health and Ageing data portal.

Risk Factors Influencing the Health of Newborns, Infants, and Toddlers

Risk factors for this population are numerous, and the previous section discussed some of them. A lack of prenatal care, the lack of immunizations during pregnancy, and continuing to smoke or use alcohol are some behaviors of the childbearing client that will lead to an increased risk of health problems for their child. At the time of birth, if the delivery does not occur in a health facility with a skilled birth attendant, this is a risk factor. Other risks to child health include not breastfeeding, malnutrition, overcrowded conditions, unsafe drinking water and food, and poor hygiene practices. Finally, a lack of knowledge regarding safety and a lack of identifying and seeking appropriate care for illnesses in this population can lead to poor health outcomes (WHO, 2023b). While these may sound like risk factors for lower socioeconomic income regions, many are risk factors in the United States. Many risk factors for this population are often interconnected and can have cumulative effects on children’s health and development. See Social Determinants Affecting Health Outcomes for more risk factors for this population.

Educational Interventions to Promote Care in Newborns, Infants, and Toddlers

Educational interventions focus on this population’s parents or caregivers and target preventing their leading causes of death and morbidity and the risk factors previously identified. Nurses play a critical role by providing caregivers with education on preventing unintentional injuries or accidents in this population. Education may involve safe sleep, play, and medication administration; sibling interactions, family members, and other visitors; and motor vehicle safety. Other significant topics of education include:

  • Immunizations
  • Nutrition (including the promotion of breastfeeding and healthy foods and drinks in early feeding)
  • Oral health care
  • Avoidance of exposure to environmental hazards (including lead, secondhand smoke, access to drugs and alcohol, firearms, violence, and trauma)
  • Importance of recognizing abnormalities or illness in newborns, infants, and toddlers
  • Developmental milestones for the age group as well as developmental needs to promote the attainment of these milestones

Learn the Signs, Act Early Tools, and Resources

Visit the CDC webpage Learn the Signs. Act Early. to learn more about the CDC’s various milestone tools and resources for caregivers, early learning center providers, health care providers, and other population health professionals, and view the following videos:

  • CDC’s Milestone Tracker Promotional Video
  • Milestones Matter for Families!
  • “Learn the Signs. Act Early.” One Director’s Story
  • “Learn the Signs. Act Early.” One Doctor’s Story

Watch the videos, and then respond to the following.

  1. Describe one benefit of using the tools and resources for caregivers.
  2. Describe one benefit of using the tools and resources for early learning center providers.
  3. Describe one benefit of using the tools and resources for nurses and other health care providers.

At the toddler stage, nurses may provide some age-appropriate health education directly to the child. Education should focus on helping them develop healthy habits and understand basic health and wellness concepts. Table 26.5 provides some examples of age-appropriate health education topics for this population.

Topic Education to Toddlers Rationale
Personal Hygiene Teach how to wash their hands, brush their teeth, and bathe properly Good hygiene habits can help prevent the spread of germs and infections.
Nutrition Encourage to eat a balanced diet including fruits, whole grains, and lean proteins; teach about healthy snacks and the importance of drinking plenty of water Eating a balanced diet early can help develop a positive attitude toward food, recognize hunger and fullness cues, and build a strong foundation for healthy eating.
Physical Activity Teach about the importance of active play, such as running, jumping, and climbing with supervision, as fun ways to stay active Physical activity will help them develop strong bones and muscles and assist in the development of coordination and balance.
Safety Teach basic safety rules, such as not touching hot stovetops or electrical outlets, wearing a helmet when riding a bike, being buckled into the car seat when riding in a vehicle, and looking both ways before crossing a street Making safety a part of daily life will allow them to become aware of dangers to avoid and simple solutions for how to avoid them.
Emotional Wellness Teach how to express their emotions in healthy ways, such as talking about their feelings, taking deep breaths when they feel upset, and going to a quiet space when overwhelmed; educate about the importance of getting enough sleep and rest Those who are socially and emotionally healthy tend to demonstrate and continue to develop several important behaviors and skills they can use in social settings.
Table 26.5 Age-Appropriate Health Education for Toddler Clients

When developing education for toddlers, the nurse should consider their short attention spans and recognize that they cannot understand complex health concepts. Ways to provide simple and interactive education may include songs, games, role-play with dolls or stuffed animals, and storytelling. Separation from parents or caregivers may cause anxiety, so this should also be considered (UCSF Benioff Children’s Hospital, 2023a).

Healthy People 2030 Goals for Newborns, Infants, and Toddlers

Childhood, particularly the early years, is a critical period for growth and development. Experiences, behaviors, and health problems can have long-term impacts during the infant and toddler years. Healthy People 2030 focuses on directly and indirectly improving health, safety, and well-being during this time. These include timely developmental screenings and recommended health services and the development of positive health behaviors, such as getting enough sleep and nutrition, to prevent diseases and injuries. Unfortunately, there are racial/ethnic and income disparities in the United States that impact these behaviors. To address these disparities, it is necessary to focus health promotion and prevention strategies on families, early childhood education programs, and neighborhoods.

Healthy People 2030

Healthy People 2030 Objectives for Infants and Toddlers

Healthy People 2030 Infants Objectives seek to “improve the health and safety of infants” (ODPHP, n.d.-c, para. 1). The health of the childbearing client before, during, and after pregnancy impacts their child’s health and well-being through their first year of life. After birth, many of the strategies to promote health focus on increasing breastfeeding rates, promoting vaccinations, promoting developmental screenings, encouraging safe sleep practice, and encouraging the correct use of car seats during transportation.

Healthy People 2030 Children Objectives address outcomes for those aged 1 through 19. Some objectives are geared specifically toward the toddler years. These include objectives related to vision, hearing, and developmental screenings; reducing emergency department visits for medication overdoses or asthma; reducing blood lead levels; reducing iron deficiency; increasing service access to children with autism spectrum disorder; increasing physical activity; and increasing vaccination rates (ODPHP, n.d.-b).

Health Promotion and Disease Prevention Activities to Improve the Health of Newborns, Infants, and Toddlers

Health promotion activities are necessary to improve the health and well-being of this population. The nurse should encourage people to breastfeed their newborns exclusively for the first six months of life, as breast milk provides all the necessary nutrients and antibodies for optimal growth and development (U.S. Department of Agriculture, 2020). Nurses should also ensure that children in this age group receive all the recommended immunizations to protect against serious infectious diseases and all the recommended screenings to identify health issues early. Various genetic, endocrine, and metabolic disorders; hearing loss; and critical congenital heart defects screenings are provided to newborns before discharge home after a hospital or birthing-center birth (CDC, 2021n). Nurses should encourage caregivers to maintain regular checkups with a health care provider for their child throughout this time frame to monitor their growth and development and address any health concerns or developmental delays.

Nurses should promote safe infant sleep practices to prevent sudden unexpected infant death (SUID). SUID is the umbrella category that describes all sudden, unexpected infant deaths from known causes, such as injury or accident, and those from unknown causes (Eunice Kennedy Shriver NICHHD, n.d., para. 2). Sudden infant death syndrome (SIDS) is defined as the sudden death of a baby younger than 1 year of age that does not have a known cause even after full investigation (Eunice Kennedy Shriver NICHHD, n.d., para. 3). About 3,400 babies in the United States die from SUID annually, including those from SIDS, accidental suffocation in a sleeping environment, and other deaths from unknown causes (CDC, 2022h).

Client Teaching Guidelines

Prevention of SUID

The community health nurse should teach caregivers to do the following:

  • Place the infant on their back for all sleep—naps and at night.
  • Use a firm, flat (not angled or inclined) sleep surface, such as a mattress in a safety-approved crib, covered by a fitted sheet.
  • Keep your baby’s crib or bassinet in the same room where you sleep until the infant is at least 6 months old.
  • Keep soft bedding such as blankets, pillows, bumper pads, and soft toys out of the infant’s sleep area.
  • Do not cover the infant’s head or allow the infant to get too hot while sleeping.
  • Do not smoke or use nicotine during pregnancy, and do not smoke or allow smoking around the infant.
  • Do not drink alcohol or use illegal drugs during pregnancy.
  • Feed the infant breast milk.
  • Visit the infant’s health care provider for regular checkups and immunizations.
  • Offer your infant a pacifier at naptime and bedtime. If breastfeeding, consider waiting to use a pacifier until breastfeeding is well established.

(See CDC, 2022i.)

Once the child is older and eating solid foods, nurses should encourage caregivers to provide a nutritious diet to promote healthy growth and development. Encourage physical activity to promote motor skills development and reduce the risk of obesity. Promoting oral health includes brushing teeth twice a day and scheduling regular dental checkups. Finally, the nurse should support caregivers in positive mental health practices, such as providing a safe and nurturing environment, fostering positive relationships, and seeking help if needed (CDC, 2022j).

Injury prevention education is imperative to reduce the risk of accidents and injuries in the infant population (CDC, 2022a). The CDC has a variety of fact sheets on safety in the home and community for infants and toddlers. These include carbon monoxide poisoning prevention, child passenger safety, safe places for childcare, emergency preparedness, food safety, medicine safety, sun safety, and water safety.

Health promotion activities for this population should also include education on preventing physical, sexual, and emotional child abuse and neglect, incorporating the following strategies (CDC, 2022a):

  • Interventions that can assist parents in strengthening household financial security
  • Family engagement
  • Referral to quality childcare agencies that are licensed or accredited
  • Education regarding parenting skills and family relationships
  • Behavioral parent training programs

Abusive head trauma (AHT), which includes shaken baby syndrome, is a preventable, life-threatening form of physical child abuse that injures an infant’s or child’s brain and can lead to serious brain injury or death (National Center for Chronic Disease Prevention and Health Promotion, 2022a). AHT typically occurs when a caregiver forcefully shakes or jerks an infant or young child. Infants’ vulnerable neck muscles and large, heavy heads make them particularly susceptible to injury. AHT can happen in a matter of seconds, even with seemingly minor force. Injuries that can result from AHT include subdural hematomas (bleeding between the brain and its protective coverings), diffuse axonal injury (widespread damage to nerve fibers in the brain, disrupting communication between brain cells), retinal hemorrhages (bleeding in the retina, which lines the back of the eye), cerebral edema (swelling of the brain), and/or skull fractures. These injuries can lead to long-term consequences such as developmental delays, intellectual disabilities, seizures, and even death.

Preventing AHT requires a multifaceted approach involving education, awareness, and support. Nurses should identify at-risk families and provide appropriate intervention and support services, including information about the dangers of shaking infants and alternative strategies for soothing a crying baby. Offering resources and support for caregivers, including stress management techniques, counseling services, and parenting classes, can help reduce frustration and improve coping mechanisms. It is mandatory that any suspected case of child abuse is reported to the appropriate services (National Center for Chronic Disease Prevention and Health Promotion, 2022a).

A variety of information for caregivers of infants and toddlers (aged 0 to 3) can be found at the CDC (2022a) Parent Information website. This website discusses the above topics in greater detail and provides schedules for developmental milestones, growth charts, and immunizations.

In addition to the strategies to prevent congenital disorders and prenatal infections discussed in this section, other newborn concerns include jaundice and vitamin K deficiency. As the child moves out of the newborn stage, other diseases and conditions, such as developmental delays, developmental disabilities, and infections, are a concern. Nurses should educate caregivers on how to prevent or detect these diseases and conditions early to mitigate complications (CDC, 2022f).

A child with a developmental delay has not gained the skills or reached the milestones that experts expect of children their age. Most developmental delays resolve independently over time (Cleveland Clinic, 2023b). Examples include delays rolling over, sitting up, crawling, and walking; trouble with fine motor skills; difficulty understanding or communicating with others; or a lack of age-appropriate social skills. Nurses should encourage caregivers to speak to their pediatrician immediately if they suspect a developmental delay or deviation from expected milestones (CDC, 2022f). Developmental screening can detect delays early, ensuring the child has early intervention services and allowing them to catch up to their peers and reach their full potential. A referral to an appropriate health care provider, such as an audiologist, speech therapist, developmental pediatrician, neurologist, physical therapist, occupational therapist, or another provider of early intervention services, may also be necessary. Early intervention is the best way to prevent long-term developmental delays or disabilities. If the child is eligible, a care team will develop an Individualized Family Service Plan (IFSP) based on the child’s and family’s particular needs.

Developmental disabilities are “a group of conditions due to an impairment in physical, learning, language, or behavior areas, which begin during the developmental period, may impact day-to-day functioning, and usually last throughout the lifetime” (CDC, 2022f, para. 1). They often begin before birth, but some can occur after birth due to injury, infections, or other factors. The cause of some developmental disabilities is unknown. Still, they are believed to be caused by a combination of factors, including genetics, parental health and behaviors during pregnancy, complications during birth, maternal infections during pregnancy, infant infections early in life, and exposure of the pregnant person or child to environmental toxins (CDC, 2022f). About one in six, or 17 percent, of children aged 3 through 17 years have one or more developmental disabilities, according to the CDC (2022f). These occur among all racial, ethnic, and socioeconomic groups. Examples include attention deficit hyperactivity disorder (ADHD), autism spectrum disorder, cerebral palsy, fragile X syndrome, Tourette syndrome, hearing loss, intellectual disabilities, learning disabilities, and vision impairment.

Infectious disease prevention in this population is very similar to any infectious disease prevention. Nurses should encourage caregivers to limit visitors during the newborn stage, especially those who are sick. Children younger than 2 are at especially high risk of developing complications from infections such as influenza, respiratory syncytial virus (RSV), or COVID-19 (CDC, 2022l). Anyone with cold-like symptoms should be taught to avoid close contact, follow cough etiquette, wash their hands often with soap and water for at least 20 seconds, and clean frequently touched surfaces. Avoiding infection can prevent complications such as pneumonia, myocarditis, and sepsis.

Primary Prevention

Primary prevention involves taking measures to prevent health problems or injuries. There are a variety of primary preventions that can be taken for newborns, infants, and toddlers. Some examples include:

  • Immunizations per the recommended schedule (CDC, 2023b)
  • Breastfeeding exclusively through age 6 months
  • Placing newborns and infants to sleep on their backs
  • Proper car seat use for infants and toddlers until they are at least 2 years old or until they reach the highest weight or height permitted by the car seat manufacturer
  • Good handwashing by the caregiver or toddler
  • Regular medical checkups

Primary prevention as early as possible in infancy can also promote health and prevent the development of chronic diseases later in life (National Center for Chronic Disease Prevention and Health Promotion, 2022a).

Secondary Prevention

Secondary prevention measures identify problems as early as possible, usually before symptoms arise. Some examples of appropriate secondary prevention measures for newborns, infants, and toddlers include:

  • Developmental screenings
  • Hearing and vision screenings
  • Early intervention services
  • Violence screening aimed at protecting children who live in high-risk environments where overt abuse has not yet occurred but is likely to occur in the future
  • Testing newborns for bilirubin levels

Tertiary Prevention

Tertiary prevention aims to minimize the negative impacts of an existing health condition or disability. For newborns, infants, and toddlers, tertiary prevention might include:

  • Rehabilitation services, such as physical therapy, occupational therapy, and speech therapy, can assist in improving the function of those with developmental disabilities.
  • Medical or surgical interventions, such as surgery, medication, and medical devices, may be needed to manage congenital heart defects, hyperbilirubinemia, or other conditions.
  • Nutritional support, such as feeding tubes, special diets, or supplements, may be needed if the child has feeding difficulties or gastrointestinal issues.
  • Behavioral interventions, such as parent training, behavior modification, or social skills training, can help with behavioral issues in toddlers.
  • Supportive services, such as respite care, counseling, and support groups, can help families cope with the challenges of caring for a child with a disability.

Integration of Sociocultural and Linguistically Responsive Interventions for Newborns, Infants, and Toddlers

Ensuring that health promotion and disease prevention interventions are culturally and linguistically appropriate can positively impact the overall well-being of this population. Cultural and linguistic diversity itself impacts child development. Language and culture shape a child’s cognitive, social, and emotional development. Because of this, the nurse should understand the importance of building relationships with the child and their caregivers, recognize cultural and linguistic diversity, and value family involvement.

The National Center on Parent, Family, and Community Engagement (2020), part of the HHS Administration for Children and Families, has recently focused on learning how understanding families’ cultural perspectives can help build positive relationships. Nurses who work with families in this way can strengthen family engagement efforts. Family engagement is the process used to build genuine relationships with families to promote strong parent-child relationships, family well-being, and better outcomes. Understanding families’ cultural beliefs, values, and priorities is the key to the family engagement process. The distinct family cultures provide meaning and direction to the lives of children. The various factors influencing families’ cultural beliefs will inform decisions about the child and the family, including health care and education decisions.

Theory in Action

Partnerships for Change: Listening to the Voices of Families

This video shows how one program effectively partnered with families and local organizations to build a strong community to contribute to community wellness, family well-being, and children’s healthy development.

As you watch the video, look for examples of the following:

Strategies

  • Community partnerships
  • Family partnerships
  • Committed program leadership
  • Culturally responsive program environment

Outcomes

  • Positive goal-oriented relationships with families
  • Family well-being
  • Families as advocates and leaders
  • Family connections to peers and community

The Public Education Foundation (2015) video Literacy, Early Learning & Family Engagement provides another glimpse of collaboration between families, educators, and health care professionals.

Sociocultural Interventions

Sociocultural interventions for this population should aim to create a safe, welcoming, and inclusive environment that recognizes and values the unique background of each child and their family. Before working with this population, nurses should benefit from training in recognizing and respecting applicable cultural differences. Family-centered care is a specific type of family engagement, described above. Family-centered care involves working collaboratively with families to understand their cultural preferences and needs to provide health care that is sensitive to their beliefs, values, and traditions. This approach may prove helpful when caring for newborns, infants, and toddlers as it promotes shared decision-making and respect between the family and the nurse.

When performing interventions with infants and toddlers, nurses should celebrate diversity. This may involve incorporating clients’ cultures through books, music, art, or other activities. Nurses can adapt play-based interventions to various cultures to support children’s cognitive, social, and emotional development. Golsäter et al. (2023) refer to this as “the ability to culturally adjust the health care” (p. 1431).

Linguistically Responsive Interventions

For families who speak languages other than the community’s dominant language, providing bilingual education and language support can be useful in fostering the child’s development. For example, a nurse could provide materials in the client’s home language and then work with bilingual staff to support communication with the family. Once again, competence training for the nurse, focused on linguistic differences, may help the nurse provide care that is responsive to the unique needs of each child and their family.

Fibla et al. (2022) describe how babies begin to learn and develop language before birth, and for many children, this includes learning multiple languages. By the year 2060, it is estimated that Latino children will constitute one-third of the three-to-four-year-old population, many of whom are dual language learners (DLLs) (Unidos U.S., 2020). DLLs are children learning two or more languages simultaneously or learning a second language while still learning their first language (Head Start, 2023). The language one speaks is instrumental in forming one’s identity, and many bilingual infants with high levels of support for both languages grow to become highly proficient in both (Fibla et al., 2022). Fibla et al. (2022) also described research that found DLLs positively contribute to reading and oral language skills across languages. They recommend the use of linguistically responsive practices to:

  • promote the visible respect and value of all languages;
  • encourage family members to support their child’s continued home language development;
  • accept all instances of communication from a child—especially when they mix two languages, known as code-switching, which should be recognized as a strength rather than a problem;
  • support every child to develop secure and nurturing relationships regardless of their home language or prior experience with English; and
  • support the continued development of a child’s home language and the acquisition and development of English.
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