Schedule for Immunizations

In the United States two organizations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention and the Committee on Infectious Diseases of the American Academy of Pediatrics, govern the recommendations for immunization policies and procedures. In Canada, recommendations are from the National Advisory Committee on Immunization under the authority of the Minister of Health and Public Health Agency of Canada. The policies of each committee are recommendations, not rules, and they change as a result of advances in the field of immunology. Nurses need to be knowledgeable about the purpose of each organization, view immunization practices in light of the needs of each individual child and the community, and keep informed of the latest advances and changes in policy.

The recommended age for beginning primary immunizations of infants is at birth or within 2 weeks of birth (Figs. 12-13 and 12-14). Children born preterm should receive the full dose of each vaccine at the appropriate chronologic age. A recommended catch-up schedule for children not immunized during infancy is available at the Centers for Disease Control and Prevention website (www.cdc.gov/vaccines/recs/schedules/child-schedule.htm). Table 12-5 describes immunization schedules for Canadian children.

Children who began primary immunization at the recommended age but fail to receive all the doses do not need to begin the series again but instead receive only the missed doses. For situations in which there is doubt that the child will return for immunization according to the optimum schedule, HBV vaccine (HepB), DTaP, IPV (poliovirus vaccine), MMR, varicella, and Hib vaccines can be administered simultaneously. Parenteral vaccines are given in separate syringes in different injection sites (American Academy of Pediatrics, 2009b).

Recommendations for Routine Immunizations*

Recommendations for Selected Immunizations

Two additional vaccines are recommended for children and adolescents at high risk for particular diseases. Two rotavirus vaccines, RotaTeq and Rotarix, have been licensed by the U.S. Food and Drug Administration for distribution in the United States. Rotavirus is one of the leading causes of severe diarrhea in infants and young children. RotaTeq is licensed for administration to infants at 6 to 12 weeks of age, with two additional doses administered at 4- to 10-week intervals but not after 32 weeks of age. The dose is 2 ml, and the product must be protected from light until administration (American Academy of Pediatrics, 2009b). Rotarix (1 ml) may be administered beginning at 6 weeks of age with a second dose at least 4 weeks after the first dose, but before 24 weeks of age. Both vaccines are administered orally.

A quadrivalent human papillomavirus (HPV) vaccine, Gardasil, has been approved and is recommended for female children and adolescents to prevent HPV-related cervical cancer. The vaccine is administered intramuscularly in three separate doses; the first dose in the series may be given at 11 to 12 years of age (minimum age 9 years), the second dose is administered 2 months after the first, and the third dose is given 6 months after the first dose (Centers for Disease Control and Prevention, 2007b). (See Fig. 12-14, footnote 2.)

Immunizations that may be used in older children and adolescents in the future and that are being evaluated include vaccines for preventing diseases such as herpes simplex virus, human cytomegalovirus, and Epstein-Barr virus. Others, such as the rabies vaccine, are discussed elsewhere in this text.

Reactions

Vaccines for routine immunizations are among the safest and most reliable drugs available. However, minor side effects do occur after many of the immunizations, and, rarely, a serious reaction may result from the vaccine. A number of inactive components are incorporated in vaccines to enhance their effectiveness and safety. Some of these components include preservatives, stabilizers, adjuvants, antibiotics (e.g., neomycin), and purified culture medium proteins (e.g., egg) to enhance effectiveness. A child may react to the preservative in the vaccine rather than the vaccine component; an example of this is the hepatitis B vaccine, which is prepared from yeast cultures. Yeast hypersensitivity therefore would preclude one from receiving that particular vaccine without consulting an allergist. Trace amounts of neomycin are used to decrease bacterial growth within certain vaccine preparations, and persons with documented anaphylactic reactions to neomycin should avoid those vaccines. Most vaccine preparations now contain vial stoppers with a synthetic rubber to prevent latex allergy reactions. In the event that an individual has a severe reaction to a vaccine and subsequent immunizations are required, an allergist may be consulted to determine the best course of action.

Some vaccines contain a preservative, thimerosal, which contains ethylmercury. Concerns regarding possible mercury poisoning in the 1990s prompted many to put off vaccination of infants and small children for fear of childhood developmental problems such as autism. A number of manufacturers have since stopped producing vaccines containing thimerosal. No local hypersensitivity reactions to thimerosal have been recorded, and studies on thimerosal and the potential link to autism or any other pervasive developmental disorder failed to establish a causal relationship between the two (DeStefano, 2007; Hviid, Stellfeld, Wohlfahrt, et al, 2003; Parker, Schwartz, Todd, et al, 2004). The Institute of Medicine (2004), following an in-depth 3-year study, issued a report concluding that there is no link between autism and the MMR vaccine or vaccines containing the preservative thimerosal. The H1N1 vaccines do not contain any additives such as thimerosal.

With inactivated antigens, such as DTaP, side effects are most likely to occur within a few hours or days of administration and are usually limited to local tenderness, erythema, and swelling at the injection site; low-grade fever; and behavioral changes (drowsiness, fretfulness, eating less, prolonged or unusual cry). Local reactions tend to be less severe when a needle of sufficient length to deposit the vaccine in the muscle is used (see Atraumatic Care box). Rarely, more severe reactions may occur, especially with pertussis and varicella. Reactions to DTaP tend to be more severe if they occurred with a previous immunization.

Hib vaccine is one of the safest vaccines available but may be associated with low-grade fever and mild local reactions at the site of injection, which resolve rapidly.

Unlike the inactivated antigens, live attenuated virus vaccines such as MMR multiply for days or weeks, and unfavorable reactions and vaccine-associated disorders can occur up to 30 to 60 days later. These reactions are usually mild, although reactions to rubella tend to be more troublesome in older children and adults.

Contraindications and Precautions

Nurses need to be aware of the reasons for withholding immunizations—both for the child’s safety in terms of avoiding reactions and for the child’s maximum benefit from receiving the vaccine. Unfounded fears and lack of knowledge regarding contraindications can needlessly prevent a child from gaining protection from life-threatening diseases. Issues that have surfaced regarding vaccines include the misconception that administering combination vaccines may overload the child’s immune system. The combined vaccines have undergone rigorous study in relation to side effects and immunogenicity rates following administration. Give parents appropriate information regarding vaccine safety, benefits, and risks so they can make informed decisions regarding vaccinations for their children. The advantage of widespread information on television and the Internet is that it is readily available at any given moment. The disadvantage is that some of this information may be incorrect, incomplete, or misleading and may influence parents to make decisions that could harm their children’s health. Parents may also receive information regarding vaccines from antivaccine groups, which advocate changes in the mass vaccination system in the United States. At times such groups may publicize information related to extremely rare events occurring after a child is immunized.

The general contraindication for all immunizations is a severe febrile illness. This precaution avoids adding the risk of adverse side effects from the vaccine to an already ill child or mistakenly identifying a symptom of the disease as having been caused by the vaccine. The presence of minor illnesses such as the common cold is not a contraindication. Live virus vaccines are generally not administered to anyone with an altered immune system, since multiplication of the virus may be enhanced, causing a severe vaccine-induced illness.

Another contraindication to live virus vaccines (MMR and varicella) is the presence of recently acquired passive immunity through blood transfusions, immunoglobulin, or maternal antibodies. Administration of MMR and varicella should be postponed for a minimum of 3 months after passive immunization with immunoglobulins and blood transfusions (except washed RBCs, which do not interfere with the immune response). Suggested intervals between administration of immunoglobulin preparations and MMR and varicella depend on the type of immune product and dosage. If the vaccine and immunoglobulin are given simultaneously because of imminent exposure to disease, the two preparations are injected at sites far from each other. Vaccination should be repeated after the suggested intervals unless there is serologic evidence of antibody production.

Pregnancy is a contraindication to MMR vaccines, although the risk of fetal damage is primarily theoretic. Breast-feeding is not a contraindication for any vaccine.

A final contraindication is a known allergic response to a previously administered vaccine or a substance in the vaccine. MMR vaccines contain minute amounts of neomycin; measles and mumps vaccines, which are grown on chick embryo tissue cultures, are not believed to contain significant amounts of egg cross-reacting proteins. Therefore only a history of anaphylactic reaction to neomycin, gelatin, or the vaccine itself is considered a contraindication to their use. To identify the rare child who may not be able to receive the vaccines, take a careful allergy history. (See Nursing Care Guidelines box, “Taking an Allergy History,” Chapter 6.) If the child has a history of anaphylaxis, report this to the practitioner before administering the vaccine. Contact dermatitis in reaction to neomycin is not considered a contraindication to immunization. Evidence indicates that children who are egg-sensitive are not at increased risk for untoward reactions to MMR vaccine. Furthermore, skin testing of egg-allergic children with vaccine has failed to predict immediate hypersensitivity reactions (American Academy of Pediatrics, 2009b).

A family history of seizures, allergies to duck meat or duck feathers, and a family history of SIDS are not considered contraindications to receiving childhood vaccines (American Academy of Pediatrics, 2009b).

Nurses are at the forefront in providing parents with appropriate information regarding childhood immunization benefits, contraindications, and side effects and the effects of nonvaccination on the child’s health. Some suggestions for communicating with parents about the benefits of immunizations in childhood include (portions adapted from Coyer, 2002; Fredrickson, Davis, and Bocchini, 2001; Rosenthal, 2004):

Administration

The principal precautions in administering immunizations include proper storage of the vaccine to protect its potency and institution of recommended procedures for injection. The nurse must be familiar with the manufacturer’s directions for storage and reconstitution of the vaccine. For example, if the vaccine is to be refrigerated, it should be stored on a center shelf, not in the door, where frequent temperature increases from opening the refrigerator can alter the vaccine’s potency. For protection against light the vial can be wrapped in aluminum foil. Periodic checks are established to ensure that no vaccine is used after its expiration date.

The DTP (or DTaP) vaccines contain an adjuvant to retain the antigen at the injection site and prolong the stimulatory effect. Because subcutaneous or intracutaneous injection of the adjuvant can cause local irritation, inflammation, or abscess formation, excellent intramuscular injection technique must be used (see Atraumatic Care box, p. 505).

The total series requires several injections, and every attempt is made to rotate the sites and administer the injections as painlessly as possible. (See discussion on intramuscular injections, Chapter 27.) When two or more injections are given at separate sites, the order of injections is arbitrary. Some practitioners suggest injecting the less painful one first. Some believe this is DTP (or DTaP), whereas others suggest the MMR or Hib vaccine. Still others advocate injecting at two sites simultaneously (requires two operators) (see Research Focus box).

Because allergic reactions can occur after injection of vaccines, take the appropriate precautions. (See Nursing Alert on anaphylactic reaction, Chapter 36.)

One of the most important features of injecting vaccines is adequate penetration of the muscle for deposition of the drug intramuscularly, not subcutaneously. In two studies, the use of longer needles in administering vaccines to a group of infants significantly decreased the incidence of localized edema and tenderness (Diggle and Deeks, 2000; Diggle, Deeks, and Pollard, 2006) (see Evidence-Based Practice box).

Because nurses often administer vaccines, they may have the responsibility for adequately informing parents of the nature, prevalence, and risks of the disease; the type of immunization product to be used; the expected benefits and risk of side effects of the vaccine; and the need for accurate immunization records. Referring to immunizations as “baby shots” and limiting the discussion to vague statements about the vaccines are unacceptable practices.

Another important nursing responsibility is accurate documentation. Each child should have an immunization record for parents to keep, especially for families who move frequently. Although immunization rates have increased significantly, health professionals should use every opportunity to encourage complete immunization of all children (see Community Focus box). Blank immunization records may be downloaded from a number of websites, including the Immunization Action Coalition (www.immunize.org), which has vaccine information and records in a number of languages.

Document the following information on the medical record: day, month, and year of administration; manufacturer and lot number of vaccine; and name, address, and title of the person administering the vaccine. Additional data to record are the site and route of administration and evidence that the parent or legal guardian gave informed consent before the immunization was administered. Report any adverse reactions after the administration of a vaccine to the Vaccine Adverse Event Reporting System (www.vaers.hhs.gov; 800-822-7967).

An additional source of vaccine information that must be given to parents (as required by the National Childhood Vaccine Injury Act, 1986) before the administration of vaccines is the VIS for the particular vaccine being administered. Practitioners are required by law to fully inform families of the risks and benefits of the vaccines. VISs are designed to provide updated information to the adult vaccinee or parents or legal guardians of children being vaccinated regarding the risks and benefits of each vaccine. The practitioner should answer questions regarding the information in the VISs. VISs are available for the following vaccines: anthrax, tetanus, diphtheria, pertussis, MMR, IPV, HPV, varicella, Hib, H1N1 influenza, influenza, meningococcal, pneumococcal, rabies, rotavirus, shingles, smallpox, yellow fever, Japanese encephalitis, typhoid, and hepatitis A and B. An updated VIS should be provided to the primary caregiver, and documentation in the patient’s chart should include the VIS title and the VIS publication date. VISs are available from state or local health departments, the Immunization Action Coalition (www.immunize.org/vis), and the Centers for Disease Control and Prevention (http://www.cdc.gov/vaccines/pubs/vis/default.htm; 800-232-4636).

In response to the concerns of manufacturers, practitioners, and parents of children with serious vaccine-associated injuries, the National Childhood Vaccine Injury Act of 1986 and the Vaccine Compensation Amendments of 1987 were passed. These laws are designed to provide fair compensation for children who are inadvertently injured and provide greater protection from liability for vaccine manufacturers and providers. (See American Academy of Pediatrics, 2009b, for further details of this program.)

Aspiration of Foreign Objects

Asphyxiation by foreign material in the respiratory tract, combined with mechanical suffocation, is one of the leading causes of fatal injury in children younger than 1 year. Both food and nonfood items are among the most common foreign bodies ingested and found in the gastrointestinal tract (Agran, Anderson, Winn, et al, 2003). The size, shape, and consistency of foods or objects are important determinants of fatal obstruction. For example, small spheric or cylindric and pliable objects (<3.2 cm [1.2 inches]) are more likely to completely obstruct the airway.

Toys are the most common cause of aspiration; therefore all toys must be carefully inspected for potential danger. Many toys that make noise or rattle, for example, have small beads inside. A broken or cracked toy can be dangerous because the beads can easily be aspirated while the infant has the toy in the mouth. Stuffed animals are potentially dangerous if any of the parts, such as the eyes or nose, are removable buttons or plastic pieces. Front buttons on infant clothes can easily be pulled off and swallowed. An active infant can grab a low-hanging mobile and quickly chew off a small piece. As soon as the infant crawls or plays on the floor, the floor must be kept free of any small articles that can be picked up and swallowed, such as coins and buttons.

Food items are the second most common cause of aspiration, and the most common offenders are hot dogs, candy, nuts, and grapes. When new foods are given to the child, nuts, hard candies, marshmallows, large amounts of peanut butter, or fruits with pits or seeds are avoided. If given to young children, hot dogs must be cut into small, irregular pieces rather than served whole or sliced into sections because their size (diameter), round shape, and consistency allow for complete occlusion of the airway. Perhaps the most dangerous foods are dried beans, which, if aspirated, enlarge when they come in contact with the wet mucosa and block the airway.

Pacifiers can also be dangerous because the entire object may be aspirated if it is small, or the nipple and shield may become detached from the handle and become lodged in the pharynx. Improvised pacifiers, such as those made from a padded nipple, also present dangers. The nipple may separate from the plastic collar and be aspirated. Thus only safe commercial pacifiers should be used, if at all. Candy pacifiers pose dangers because the candy portion can dislodge from the circular base and be aspirated. To be safe, pacifiers should have:

Using a syringe to accurately measure and dispense oral liquid medications to young children has become common practice. However, a syringe with a cap becomes a potential aspiration hazard. The newer medication administration syringes for children do not have a removable cap. Other items that can easily be aspirated include soda and fruit juice bottle tops or caps, aluminum soda can pop-top rings that tear off easily, and small key rings (<1.5 inches in diameter).

Suffocation

According to one survey, accidental suffocation and strangulation rates among infants quadrupled between 1984 and 2004 in the United States; African-American boys under the age of 4 months were most affected (Shapiro-Mendoza, Kimball, Tomashek, et al, 2009). Schnitzer (2006) indicates that almost 67% of injury deaths in infants are due to suffocation. Mechanical suffocation includes suffocation by covering of the airway (i.e., mouth and nose); by pressure on the throat and chest; and by exclusion of air, such as by refrigerator entrapment. Nonfood items cause the majority of deaths in young children. Latex balloons, whether partially inflated, uninflated, or popped, are the leading cause of pediatric choking deaths from children’s products. They should be kept away from infants and young children.

The bed or crib poses a number of hazards. An infant who is placed in a bed under tucked-in blankets and sheets can be caught under them and unable to wriggle free. (See Sudden Infant Death Syndrome, Chapter 13.) Bumper crib pads are a common cause of death in infants either as a result of suffocation or strangulation on the bumper ties (Thach, Rutherford, and Harris, 2007). Baby pillows filled with plastic foam beads that make them resemble small bean bags are dangerous; very young infants are suffocated when the pillow contours to the face and blocks the airway. There are potential dangers in adults sleeping with an infant because of the possibility of their rolling over and smothering the child (overlaying), especially when alcohol, tobacco, or recreational drugs are involved. According to U.S. federal regulations, the distance between crib slats should not be more than 6 cm (2.375 inches), roughly the width of three adult fingers. Mattresses should fit snugly against the slats; bumper pads are no longer recommended. A general rule is that the mattress is too small if two adult fingers can be placed between the mattress and crib or bed side. A temporary solution is to place large, rolled towels in the space to create a snug fit.

Corner post extensions on cribs are another source of strangulation. Children have died when their clothing caught on raised corner posts as they climbed out of the crib. Voluntary manufacturing standards state that corner post extensions not exceed inch. However, the safety of any extension is questionable. Decorative extensions need to be removed from cribs. Ideally, information regarding correct crib design should be given prenatally, before parents have purchased or borrowed a crib.*

Mesh-sided playpens and cribs can result in death if the sides are left in the lowered position. Infants have suffocated when they fell off the edge of the mattress and the head or chest was compressed between the floorboard and mesh side. Cribs should be located away from windows, where drape or blind cords can become wrapped around the infant’s neck.

Another cause of suffocation is plastic bags. Large plastic bags used over garments are lightweight and can easily and quickly be wrapped around the head of an active infant or pressed against the face. For this reason, pillows and mattresses should not be covered with plastic. Older infants may play with a plastic bag and accidentally pull it over their heads. Because plastic is nonporous, suffocation occurs in a matter of minutes.

Cords located near the infant or tied around the infant’s neck can potentially cause strangulation. Bibs are removed after meals, and objects such as pacifiers are never hung on a string around the infant’s neck. This is a common practice in some cultures that can be remedied by tying a short string to a pacifier and pinning the string to the child’s shirt.

Toys that have strings attached, such as a telephone, or toys that are tied to cribs or playpens can be hazards because the string can become wrapped around the child’s neck or the child can become entrapped in the toy. As a precaution, all cords should be less than 30 cm (12 inches) long. Crib toys should be hung high enough that the infant cannot become entangled in them and should no longer be used once the child is able to reach them.

Motor Vehicle Injuries

Automobile injuries are the leading cause of accidental death in children between the ages of 1 and 9 years (Centers for Disease Control and Prevention, 2007a). A significant number of nonfatal vehicle-related injuries in children between 1 and 4 years of age occur as a result of back-over while children are playing in a driveway (Centers for Disease Control and Prevention, 2005b). In addition, a significant number of infants are injured or die from improper restraint within the vehicle, most often from riding on the lap of another occupant. Desapriya, Joshi, Subwarzi, and colleagues (2008) found that falls accounted for a significant proportion of injuries (98%) in infants from birth to 4 months of age as a result of inappropriate use of a car restraint system. Reports indicate that child restraint use decreases with increasing age of children and increasing number of occupants. Lack of proper child restraint continues to be a major factor in fatal accidents involving children. All infants must be secured in a federally approved restraint rather than held or placed on the seat of the car. There is no safe alternative.

Infant restraints are designed either as an infant-only model or as a convertible infant-toddler model. Either restraint is a semireclined seat that faces the rear of the car. A rear-facing car seat provides the best protection for the disproportionately heavy head and weak neck of an infant (Fig. 12-15). This position minimizes the stress on the neck by spreading the forces of a frontal crash over the entire back, neck, and head; the spine is supported by the back of the car seat. If the seat were faced forward, the head would whip forward because of the force of the crash, creating enormous stress on the neck. A recent study indicated that children 0 to 3 years of age riding properly restrained in the middle of the back seat had a 43% lower risk of injury than children riding in the outboard (window) seat during a crash (Kallan, Durbin, Arbogast, et al, 2008). Another study showed that children 0 to 23 months riding in a rear-facing restraint were less likely to be injured than those riding in a forward-facing restraint (Henary, Sherwood, Crandall, et al, 2007).

The restraint is anchored to the vehicle with the vehicle’s seat belt, and the restraint has a harness system for securing the infant. Some harness systems require a clip to keep the shoulder straps correctly positioned. Newer vehicles (manufactured after 1999) have tether straps that attach to anchors in the car seat to better secure the seat and minimize forward movement of the forward-facing convertible seats in the event of an accident. The LATCH (lower anchor and tether for children) system provides car seat anchors between the front cushion and backrest so that the seat belt does not have to be used. Some automobiles have tether straps for rear-facing infant-only seats as well. (See Chapter 14.) Although many infant restraints can be recliners, they are used in the car only in the position specified by the manufacturer.

It is now recommended that all infants and toddlers ride in a rear-facing car safety seat until they have reached the age of 2 years or they reach the highest weight or height recommended by the car seat manufacturer (American Academy of Pediatrics, 2011).

Rear-facing infant safety seats must not be placed in the front seats of cars equipped with an air bag on the passenger side. If an infant safety seat is placed in the passenger seat with an air bag, the child could be seriously injured if the air bag is released, since rear-facing infant seats extend closer to the dashboard. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat. The back seat is the safest area of the car. If the back seat is not an option, an infant restraint may be positioned in the front seat provided that the seat belt can be locked into position and there is no passenger-side air bag. If there is a passenger-side air bag and the child has special health care needs or constant observation is recommended by the practitioner and no other adult is available to ride in the back seat with the child, an on/off switch may be installed to prevent the air bag from deploying and injuring the child riding in the front seat. In vehicles without a back seat, it is best to place the front passenger seat as far back as possible and use appropriate child safety restraint. The new, “smart” air bags include features that make it possible to deactivate the air bag temporarily if an infant must ride in the front seat. Remind parents to reactivate the airbag once the infant is no longer riding in the front seat.* (See discussion of air bag safety in Chapter 14.)

For restraints to be effective, they must be used properly. Dressing the infant in an outfit with sleeves and legs allows the harness to hold the child securely in the seat. A small blanket or towel rolled tightly can be placed on either side of the head to minimize movement and keep the infant’s hips against the back of the seat. Padding between the infant’s legs and crotch can prevent slouching. Thick, soft padding is not placed under the infant or behind the back because during the impact the padding will compress, leaving the harness straps loose. Preterm infants being discharged home should be secured in an appropriate car seat restraint as it would be placed in the car and the infant’s oxygen saturations monitored for a determined period to detect any potential problems with airway occlusion. (For further discussion of car seat restraints, see Chapter 14; for preterm infant car restraint test guidelines, see Family-Centered Care box, p. 341.)

Another automobile-related hazard for infants is overheating (hyperthermia) and subsequent death when left in a vehicle in hot weather (>26.4° C [80° F]). Infants dissipate heat poorly, and an increase in body temperature may cause death in a few hours. Caution parents against leaving infants in a vehicle alone for any reason. A small sign or placard has been designed to hang in the rear-view mirror to remind the parent that there is a child in the back seat. Busy parents may forget the child in the back when preoccupied with errands, children’s school and extracurricular activities, and busy work schedules.

Falls

Residential injuries, especially falls, accounted for the highest incidence of unintentional injuries to children seen in emergency departments in the United States (Phelan, Khoury, Kalkwarf, et al, 2005). A study of childhood injuries found that beginning at the age of 3 to 5 months, the incidence of falls increased dramatically with increasing age, peaking at 15 to 17 months of age. Most falls were from heights such as furniture, stairs, and buildings (Agran, Anderson, Winn, et al, 2003). A large percentage of infants have fallen as a result of being dropped or falling out of car seats, down stairs, or from child walkers (Pickett, Streight, Simpson, et al, 2003; Dedoukou, Spyridopoulos, Kedikoglou, et al, 2004). Falls from shopping carts and bunk beds also contribute to a significant number of injuries in small children (Wright, Griffin, MacLennan, et al, 2008; D’Souza, Smith, and McKenzie, 2008).

Infant walkers are responsible for a number of different types of injuries that occur when the walker tips over or falls down stairs. Warn parents of these dangers and encourage them to keep constant watch on their child’s activities; discourage the use of walkers. The American Academy of Pediatrics (2001) does not recommend the use of walkers with wheels. One alternative is to use a stationary play station with a seat similar to that of a walker. There is no evidence that infant walkers help infants walk sooner.

Once infants are mobile, they should not be allowed to crawl unsupervised on any raised surface, near stairs, or near any water reservoir. Gates should be used at the bottom and top of stairs, since both present dangers to the crawling and climbing infant. As children begin to pull themselves to a standing position, heavy objects, such as unsturdy furniture, televisions, compact disc players, or any freestanding item (e.g., wrought iron fish tank stands or concrete birdbath), can be extremely dangerous if pulled down on top of the child. To prevent injury from furniture tipping over, place televisions on lower furniture and as far back as possible. Angle braces or anchors can secure furniture to walls.

Poisoning

Poisoning is one of the major causes of death in children younger than 5 years of age. The highest incidence occurs in the 2-year-old group, with the second highest incidence occurring in 1-year-old children. Infants who do not crawl are relatively free from the danger of poisonous agents because they are immobile. However, once they become mobile, danger from poisoning is almost everywhere. The average home contains more than 500 toxic substances, and approximately one third of all poisonings occur in the kitchen.

The major reason for ingestion of poisons is improper storage. To protect the infant, toxic agents should not be placed on a low shelf, table, or floor. Plants are another source of poisoning for infants. Plants are commonly placed on the floor, and the leaves or flowers are attractive and easy to pull off. More than 700 species of plants are known to cause illness or death. Common household over-the-counter medications such as acetaminophen and cold and cough preparations, cosmetics and personal care products, and cleaning products are also sources of childhood poisoning (Wilkerson, Northington, and Fisher, 2005).

Another danger is ingestion of the button-sized batteries used in devices such as hearing aids, calculators, watches, and cameras. Because they are bright and shiny, they are attractive to children. However, they can cause severe morbidity, even death, if lodged in the esophagus. The strong alkali in a battery can leak and cause a severe caustic burn. As a precaution, small batteries must be safely stored and discarded where young children cannot easily retrieve them.

Not all poisonings result from ingestion; another possible route is inhalation, such as inhaling chlorine vapors from household cleaning or pool supplies. Passive cocaine toxicity has occurred in young children exposed to freebase cocaine (“crack”) smoking by adults. The production of methamphetamines, a common central nervous system stimulant also known as ice, speed, or crystal, involves a number of chemicals that may be toxic alone (contact or ingestion) or during the production (cooking) of the drug itself. Methamphetamine laboratories are commonly in household areas where children may be exposed to harmful inhalants and to open fires where meth is “cooked.” Methamphetamine laboratories are also often mobile, and children may be similarly exposed to dangerous chemicals (Farst, Duncan, Moss, et al, 2007). Methamphetamine use and exposure have been shown to cause developmental problems and short- and long-term brain damage, particularly in children. Reports of the number of children exposed daily to methamphetamine laboratories in the United States and Canada are alarming. Such children are also at high risk for abuse and neglect because their caretakers are preoccupied with production, sale, and use of the drug (Bellemare, 2008; Matteucci, Auten, Crowley, et al, 2007; Mecham and Melini, 2002). Children should be protected from environments in which inhaled toxins exist. (See Chapter 32 for discussion of effects of chemical substances on the fetus and neonate.)

The only certain way to prevent poisoning is to remove toxic agents, which means placing containers out of the infant’s reach or contact. Because crawling infants soon become climbing toddlers, it is best to keep all toxic agents, especially drugs, in a locked cabinet. Special plastic hooks can be attached to the inside of cabinet doors to keep them securely closed. Firm thumb pressure is required to unlatch the hook, and small children are usually unable to manipulate them. Locks are best, but for frequently used cleaning agents, such as those often kept under a kitchen sink, hooks are a practical alternative.

With several hundred toxic substances in each house, locking them all up can present a problem. Potentially hazardous substances should not be stored in any type of food container. A popular container used to store toxic liquids is a soda or pop bottle. A child who is unaware of the dangerous contents is vulnerable to poisoning. Parents should know the telephone number of local poison control centers and call in the event of a suspected poisoning. Chapter 16 discusses emergency measures for poisoning.

Burns

Scalding from water that is too hot; excessive sunburn; and burns from house fires, electrical wires, sockets, and heating elements such as radiators, registers, and floor furnaces cause a significant number of deaths and many more injuries in infants. The infant’s skin is particularly sensitive to irritation, and the mechanisms for temperature perception are not completely developed. As a general precaution, all homes should have smoke alarms installed near the bedroom areas and on each level of the building.

Scald burns from hot tap water can be prevented by lowering the hot water heater to a safe temperature of 49° C (120° F). In addition, parents should check the bath water before placing the infant in it. The two most common types of scald injury are from the child pulling a hot pan of water off a stove or elevated surface or overturning a container of hot water on herself or himself (Drago, 2005). The handles of cooking utensils should be turned toward the back of the stove. When the infant is underfoot, caretakers should avoid pouring hot liquids and cooking with hot oil. Hanging tablecloths should also be out of the infant’s reach to prevent pulling hot items off the table.

Scalds can also occur from bathing infants in the kitchen sink when the garbage disposal, occluded with debris, causes the draining dishwasher effluent to back up into the sink. The temperature of the effluent from a dishwasher is typically that of the maximum water temperature of the household water heater, but many dishwashers are equipped with heating elements that heat water to an even higher temperature. As a precaution, instruct caregivers to avoid bathing small children in the kitchen sink while the dishwasher is running.

If formula or food is warmed in a microwave oven, parents must check it before feeding because the container may remain cool while the contents are hot. Oropharyngeal burns from the contents of baby bottles heated in a microwave have been reported. Another danger is explosion of the bottle from the buildup of steam. Because of these dangers, parents should avoid microwaving infant formula or food or do it using the guidelines in the Family-Centered Care box on p. 490.

Sunburn can be a source of a first- or second-degree burn. Exposure to direct sunlight should be avoided for the first 6 months. When infants are in the sun, the body, especially the face and head, should be covered. Sunscreen can be used on older infants but should be used on small areas of the body and sparingly in infants under 6 months. (See Sunburn, Chapter 18.) Although dark-skinned infants burn less readily, their thin skin can become sunburned and needs protection.

Electrical outlets should be covered with protective plastic caps that prevent the child from sucking on the outlet or putting metal objects into it. Live wires are placed out of reach so that curious infants cannot chew on them and break the rubber coating. Infants should not be allowed to play near television sets, stereo units, or other appliances, whether these units are turned on or off, because infants cannot determine when the appliance is safe.

Any heat-producing element should have a guard in front of it. Fireplaces should be well screened because they are appealing and within easy access. Small portable heaters should be placed on a high surface. Floor furnaces should have barrier gates to prevent children from crawling or walking over them. Burning cigarettes, candles, and incense should be kept out of reach, and infants should not be held by a smoking adult because falling ashes are a hazard, especially to the eyes. Heated-mist vaporizers are a source of burns and should not be used. If humidity is needed, only cool mist vaporizers are safe.

By law, all infant sleepwear must be flame retardant. Unfortunately, this does not apply to all infant clothing. Flame-retardant fabric is not the ultimate protection against burns. Repeated washing reduces the flame-retardant properties, and the use of soap or bleach destroys the protection. If sleepwear is home sewn, advise parents to look for specially treated, flame-retardant fabric.

Another type of thermal injury occurs when children are exposed to excessive heat during confinement in poorly ventilated vehicles. The practice of leaving the windows open a couple of inches is not protective. The nurse should caution parents never to leave children in parked cars, especially when the automobile is in direct sunlight.

Children can also be burned by overheated metal hardware and vinyl seats in cars parked in the sun. As a precaution, the surface heat of car restraints should be determined before placing children in them. Covering the restraints and hardware (such as metal latches on seat belts) may be necessary to prevent skin burns. An additional safeguard is buying a light-colored restraint, which absorbs less heat.

Drowning

Drowning in this age-group can occur in just an inch or 2 of water. Consequently, infants should always be supervised in a bathtub and near a source of water such as a swimming pool, lake, toilet, or bucket. A survey found that most drownings among infants younger than age 1 year took place in a toilet, bathtub, or bucket (Lassman, 2002). Five-gallon buckets are particularly dangerous because the child may inadvertently fall in head first and, because of the weight of the upper body at this age, may be unable to withdraw from the bucket. Somers, Chiasson, and Smith (2006) noted that 72% of pediatric bathtub drownings occurred in infants under 12 months of age, and inadequate adult supervision was the leading associated factor (89% of cases). Organized swimming instruction is not recommended for children younger than 4 years of age, since it may lead to a false sense of security (American Academy of Pediatrics, 2003). Infants cannot learn the elements of water safety or react appropriately in an emergency. Therefore all young children need to be considered at risk when near water. Infants and toddlers are also at increased risk of infection and seizures from swallowing large amounts of water.

Bodily Damage

Injuries can occur in numerous ways. Sharp, jagged-edged objects can cause wounds in the skin. Long-pointed items, such as a toothpick or fork, can be poked into the eye or ear, causing serious damage. Such articles should be safely stored away from the infant’s reach. Forks are best avoided for self-feeding until the child has mastered the spoon, usually by age 18 months.

In addition to hazards such as aspiration, infants can place small articles in the ear or nose, and excessive noise from toys can result in sensorineural hearing loss. Although toys with the highest noise levels are model airplanes, air guns, and toy cap guns, even common squeaking toys used by young children may be harmful if placed close to the ear.

A Centers for Disease Control and Prevention report (2008a) highlights the fact that in 2005 to 2006, 19% of child maltreatment fatalities in the United States occurred in infants less than 1 year of age. Homicide statistics suggest the fatality risk is highest in the infant’s first week of life. Nonfatal maltreatment data for the same period indicate that 38.8% of infants maltreated were less than 1 month of age; 84% of those were less than 1 week old. Neglect and physical abuse were the most frequently reported forms of maltreatment. A high rate of battering injury has been reported in infants 0 to 5 months (Agran, Anderson, Winn, et al, 2003).

Another commonly unrecognized danger to infants is animal attacks. As newcomers to the home, helpless infants can provoke jealousy in animals, especially dogs and cats. Parents must be aware and protect the child from household pets and farm animals. (See Mammal Bites, Chapter 18.)

Nurse’s Role in Injury Prevention

The task of injury prevention begins to be appreciated only when the potential environmental dangers to which infants are vulnerable are considered. Injury prevention and parent education should be handled on a growth and developmental basis. It is simply impossible to completely protect infants and small children from all potential dangers without placing them in a sterile, impractical environment. However, a large percentage of childhood deaths continue to occur as a result of preventable injuries (Martin, Kochanek, Strobino, et al, 2005). Nurses must be aware of the possible causes of injury in each age-group to provide anticipatory, preventive teaching. For example, the nurse should discuss guidelines for injury prevention during infancy (see Box 12-6) before the child reaches the susceptible age-group. Preventive teaching ideally begins during pregnancy.

Two thirds of all injuries to children occur in the home, and therefore safety is essential to emphasize with parents. The nurse can give parents a home safety checklist to increase their awareness of danger areas in the home and assist them in implementing safety devices and practices before an injury occurs (see Family-Centered Care box). Hands-on displays such as cabinet latches or toilet seat locks can familiarize parents with inexpensive, commercial devices that can be used in the home to prevent injuries.

To help parents appreciate the dangers present in their home to young children, suggest that they get eye level with the floor to survey the environment from a curious child’s view.

Injury prevention requires protection of the child and education of the caregiver. Nurses in ambulatory care settings; health maintenance centers; and home health, public health, or visiting nurse agencies are in a most favorable position for injury education. This does not exclude nurses in inpatient facilities, who could use visiting times for discussing this topic. Although early postpartum discharge may be restrictive, this is an excellent opportunity to introduce the family to infant safety and safety for other children in the household as well. Pamphlets, safety checklists, and brief information sessions describing potential dangers and remedies aimed at preventing injury can help the new family get off to a good beginning with the new infant.

One approach to teaching injury prevention is to relate why children in various age-groups are prone to specific types of injuries. Stressing prevention is just as important as emphasizing why the injury occurs. However, injury prevention must also be practical. Asking parents for their ideas leads to realistic suggestions they can follow.

Parents need to remember that infants and young children cannot anticipate danger or understand when it is or is not present. Although parents can always explain to the child why something is dangerous, they also must remember that small children need to be physically removed from the situation. It is not easy to teach safety, supervise closely, and refrain from saying “no” a hundred times a day. Parents become acutely aware of this dilemma as soon as the infant learns to crawl and pull up to furniture. Preventing injuries is usually the first reason for limit setting and discipline, but limits are also set to prevent damage to valuable household objects. When small children are in the home, parents must remove or guard dangerous objects and place valuable articles out of reach.

When children learn the meaning of “no,” they should also learn what “yes” means. Parents should praise children for playing with suitable toys, reinforce their efforts at behaving or listening, and provide innovative and creative recreational toys for them. Infants love to tear paper and avidly pursue books, magazines, or newspapers left on the floor. Instead of always scolding them for destroying a valued book, keep child-safe books (such as those constructed of fabric) available for them to play with. If they enjoy pots and pans, a cabinet can be arranged with safe utensils for them to explore.

One additional factor must be stressed concerning injury prevention and education. Children are imitators; they copy what they see and hear. Thus practicing safety teaches safety, a rule that applies to parents and their children and to nurses and their clients. Saying one thing but doing another confuses children and can lead to difficulties as the child grows older.

• The child’s biologic development encompasses proportional changes; sensory changes, including binocularity, depth perception, and visual preference; maturation of biologic systems; fine motor development; and gross motor development.

• Erikson’s theory of psychosocial development states that, from birth to 1 year, the infant is concerned with acquiring a sense of trust while overcoming a sense of mistrust.

• Piaget’s theory of cognitive development, as it applies to the infant, focuses on the sensorimotor phase, which includes the use of reflexes, primary circular reactions, secondary circular reactions, and coordination of secondary schemas and their application to new situations.

• Development of body image begins in infancy; by 1 year of age infants recognize that they are distinct from their parents.

• Social development of the infant is guided by attachment, language development, personal-social behavior, and participation in play.

• Temperament influences the type of interaction that occurs between the child, parents, and siblings.

• Parents face many concerns, including infant fears, daycare, limit setting and discipline, thumb sucking and pacifier use, teething, and choice of infant shoes.

• Breast milk is the most desirable food for the infant for the first 6 to 12 months. Commercial iron-fortified formula is an acceptable choice for infant nutrition when breast-feeding is not an option, followed by gradual introduction of solid food during the second 6 months. Whole milk is not recommended until after 12 months.

• Common sleep problems that develop during infancy—and that are easily prevented—are associated with night crying and feeding. Nurses should instruct the parents, after careful assessment, in strategies to deal with the specific problem.

• Cleaning the gums and teeth regularly and appropriate dietary intake promote good dental health.

• Recommended routine immunizations include those for hepatitis B, hepatitis A, diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, pneumococcal, chickenpox, meningococcal, influenza, and H. influenzae type b.

• Combination vaccines are effective and decrease the total amount of injections a child must receive.

• Because injuries are a major cause of death during infancy, parents should be alerted to dangers of aspiration of foreign objects, suffocation, falls, poisoning, burns, motor vehicle injuries, and bodily damage, as well as preventive actions needed to make the environment safe for infants.

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