Recommendations for Selected Immunizations

Two additional vaccines are recommended for children and adolescents at high risk for particular diseases. In February 2006 a new rotavirus vaccine, RotaTeq, received a license from the U.S. Food and Drug Administration (FDA) for distribution in the United States. A second rotavirus vaccine, Rotarix, is licensed for use in Europe, and application to the FDA for use in the United States was made in late 2007. Rotavirus is one of the leading causes of severe diarrhea in infants and young children. A previous rotavirus vaccine was removed from the market in the late 1990s because of its association with intussusception. The new oral rotavirus vaccine 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 (US Food and Drug Administration, 2006) (see Fig. 10-11, A).

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), while the second dose is administered 2 months after the first, with the third dose being given 6 months after the first dose (Centers for Disease Control and Prevention, 2007b) (see Fig. 10-11, B).

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. A vaccine for respiratory syncytial virus is currently being tested in animal models with apparent success. 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.

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). Rarely, more severe reactions may occur, especially with pertussis (see Table 10-6). 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. Fever (temperature >38.5° C [101.3° F]) may rarely occur.

A number of inactive components are incorporated in vaccines to enhance their effectiveness and safety. Some of these components include preservatives, stabilizers, adjuvants, antibiotics, and purified culture medium proteins to enhance effectiveness. A child may react to the preservative in the vaccine rather than the vaccine component; an example of this is the HepB vaccine, which is prepared from yeast cultures. Yeast hypersensitivity would preclude one from receiving that particular vaccine (Schuval, 2003). 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 (Schuval, 2003).

A commonly observed reaction includes localized erythema and induration, which may occur when the vaccine is not administered deeply enough into the muscle. This reaction can be prevented by ensuring that needle length is appropriate for the child’s muscle size. Although many vaccine preparations are commercially available in prepackaged form, the enclosed needle may not be of adequate length to penetrate the muscle in certain children (see Atraumatic Care box, p. 360, and Administration, below).

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 for 30 to 60 days. 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 having 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.

Parents must be given appropriate information regarding vaccine safety, benefits, and risks so they can make informed decisions regarding vaccinations for their children (Koslap-Petraco and Parsons, 2003; Fredrickson, Davis, Arnold, and others, 2004). The advantage of widespread media coverage on television and the Internet is that information is readily available at any given moment; the disadvantage may rest in the fact that information—rather, misinformation—from questionable sources is also readily available and may influence parents to make decisions that may have deleterious consequences for their children’s health. In one survey, parents’ fear of side effects was the most commonly expressed (52%) reason for vaccination refusal; other common reasons included the belief that the disease was not harmful (26%), religious beliefs (28%), and philosophical reasons (26%) (Fredrickson, Davis, Arnold, and others, 2004). The contraindications to the usual childhood vaccines are presented in Table 10-6. See also Family-Centered Care box.

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 DTaP vaccines contain the adjuvant alum 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, attention to excellent intramuscular injection technique must be used (see Atraumatic Care box, p. 360, and Table 10-7).

One of the most important features of injecting vaccines is adequate penetration of the muscle for deposition of the drug intramuscularly and not subcutaneously. The use of appropriate needle length is an essential component of administering vaccines. In two studies, the use of longer needles significantly decreased the incidence of localized edema and tenderness when vaccines were administered to a group of infants (Diggle and Deeks, 2000; Diggle, Deeks, and Pollard, 2006) (see Intramuscular Administration, Chapter 22).

The total series requires several injections, and every attempt is made to rotate the sites and administer the injections as painlessly as possible (see Intramuscular Administration, Chapter 22). When two or more injections are given at separate sites, the order of injections is arbitrary. Because allergic reactions can occur after injection of vaccines, appropriate precautions are taken (see Anaphylaxis, Chapter 25).

Nurses often administer vaccines and thus 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 the 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,^* which has vaccine information and records in a number of languages.

The following information is documented on the medical record: day, month, and year of administration; manufacturer and lot number of vaccine; and the 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. Any adverse reactions after the administration of any vaccine are reported to the Vaccine Adverse Event Reporting System.^*

An additional source of vaccine information that must be given to parents (by law; National Childhood Vaccine Injury Act, 1986) before the administration of given vaccines is the vaccine information statement (VIS) for the particular vaccine being administered. Practitioners are required 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. Questions regarding the information in the VISs should be answered by the practitioner. VISs are available for the following vaccines: anthrax, tetanus, diphtheria, pertussis, MMR, IPV, varicella, Hib, influenza, meningococcal, pneumococcal, rabies, smallpox, yellow fever, Japanese encephalitis, rotavirus, human papillomavirus, typhoid, HPV, HepA, and HepB. An updated VIS should be provided, and documentation in the patient’s chart should state that the VIS was given and include the publication date of the VIS. VISs are available from state or local health departments or from the Immunization Action Coalition^* and Centers for Disease Control and Prevention.^†

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. Basically, 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.

One survey found that a large percentage (65%) of children under the age of 2 years were not fully immunized in a large health maintenance organization population, perhaps because of the lack of coordinated immunization information. In addition, the study found that more than 51% had at least one immunization error and more than 20% had an unnecessary or incorrect immunization based on current recommendations (Mell, Ogren, Davis, and others, 2005). Therefore recommendations are in place to improve the overall effectiveness of the national vaccination program. It has been suggested that local or national computerized registries and improved record tracking systems be established to improve communication; additional recommendations include improving provider knowledge of immunization status and contraindications for administering vaccines and simplifying the immunization guidelines (Lee and Bernstein, 2005).

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, and others, 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 (less than 3.2 cm [1.25 inches]) are more likely to completely obstruct the airway. Unfortunately, common household items can be deadly to infants.

As soon as infants have the ability to find their mouth, they are vulnerable to aspiration of small objects, such as those left within reach or removable parts of objects that may on initial inspection appear safe. Toys are one of the leading sources for asphyxiation; therefore all toys must be carefully inspected for potential danger. Rattles, for example, have small beads in them to produce noise. A broken or cracked rattle can be dangerous because the beads can easily be aspirated while the infant has the toy in the mouth. Stuffed animals are another potentially dangerous toy if any of the parts, such as the eyes or nose, are removable buttons or plastic pieces. 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.

When infant clothes are purchased, the type of closure is important. A front button can easily be pulled off and swallowed. Safety pins for diapers are kept closed and away from the dressing table. Even though a young infant may not search for them, practicing this good habit from the beginning prevents future injuries.

Food items are also a very common cause of aspiration in children, 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. When traveling (especially in airplanes) or entertaining, parents must keep snack foods such as peanuts and popcorn away from young children. If given to young children, hot dogs must be cut into small, irregular pieces rather than served whole or sliced into sections, since 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 in hospitals from a padded nipple, also present dangers. The nipple may separate from the plastic collar and be aspirated. In addition, parents may continue to offer this pacifier to the infant at home. To prevent the hazards of improvised pacifiers, hospitals should use only safe commercial types. Pacifiers should not be altered from their original shape to encourage or discourage usage. 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, the syringe cap is a potential aspiration hazard. As a precaution, keep parts of medication devices out of the reach of children and use a syringe designed for childhood medication administration.

Even safety devices can be dangerous. To prevent tampering, items (such as baby food jars) may be covered with a plastic oversleeve. The tear-down strip can be aspirated and is very difficult to locate because it is clear.

Another hazardous substance if aspirated is baby powder, which is usually a mixture of talc (hydrous magnesium silicate) and other silicates. Although the use of talc has been discouraged, it is a common baby care product that can cause severe and often fatal aspiration pneumonia. One of the factors involved in talc aspiration is the similar appearance of baby powder containers and nursing bottles. Talc containers often become favorite playthings and are placed in the mouth. Improperly using powder by sprinkling it directly on the skin creates a cloud of talc dust that is easily inhaled. Parents are advised of the danger of baby powder and are discouraged from using it. If they prefer to use a powder, a cornstarch preparation can be substituted (see Diaper Dermatitis, Chapter 30). Whenever a powder is used, it is placed in the hand and then applied to the skin, never shaken directly from the container to the skin. The container is kept closed and immediately stored in a safe place, especially away from curious toddlers, who often imitate caregiving activities and may shake it on the infant.

Suffocation

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. Even the practice of inflating latex gloves to amuse children in health care settings may pose a danger, especially if the child is latex sensitive. Future deaths may be avoided by changing balloon design and materials and substituting Mylar or paper balloons. In addition, the accessibility of the plastic linings of diapers used on the infant or on dolls is especially dangerous to young children.

The type of 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. Baby pillows filled with plastic foam beads that make them resemble small beanbags 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. Studies of sudden and unexpected infant deaths have shown that such infants were found in unsafe sleeping positions (prone or on soft bedding surface) or were placed to sleep in a bed, sofa, or chair not intended for infant sleeping. Another common cause of infant suffocation was wedging between a bed or mattress and a wall and oronasal obstruction by a plastic bag.

Infant strangulation may occur if the infant’s head becomes caught between the crib slats and mattress or objects close to the crib. Suffocation deaths are not confined to cribs; ill-fitting mattresses in adult or youth beds, bunk beds, and waterbeds have also been reported. According to U.S. federal regulation, the distance between crib slats should not be more than 2.375 inches (6 cm), roughly the width of three adult fingers. Mattresses and bumper pads should fit snugly against the slats. 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 0.0625 inch (0.16 cm). 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. Parents should be advised of this danger and encouraged to always keep the sides locked securely in the up position whenever the child is in the playpen or crib.

The crib should be positioned away from large furniture, since children who crawl out of the crib may become caught between the two objects. Cribs should also be located away from windows, where any type of drape or blind cords (split or single) 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.

Bibs are removed at bedtime, 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 after the child is able to reach them.

If applied too loosely or left unfastened, restraining straps can be a hazard. For example, a child may slide off a high chair beneath the tray and become strangled on the loose strap. All straps should be fastened securely.

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 injuries while playing in a driveway (Centers for Disease Control and Prevention, 2005b). However, many infants are injured or die from improper restraint within the vehicle, most often while riding on the lap of another occupant. 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 (Fig. 10-13). Either restraint is a semireclined seat when facing the rear of the car. A rear-facing car seat provides the best protection for the disproportionately heavy head and weak neck of a young child. 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. One recent study has shown that children from birth to 23 months experienced fewer injuries when riding in rear-facing car restraints (Henary, Sherwood, Crandall, and others, 2007). The findings suggest that guidelines may soon be revised to recommend a rear-facing car restraint position in children over 1 year of age.

The restraint is anchored to the vehicle with the vehicle’s seat belt or LATCH (lower anchors and tethers for children) system, and the restraint has a harness system for securing the infant (see Fig. 12-11). The five-point harness system provides the most effective support for infant restraint; the three-point harness system secures only the upper body. Many infant seats have a plastic base that can be left in the car; the seat latches or clicks into the base so that the base does not have to be installed each time the car seat is removed. The LATCH system provides car seat anchors between the front cushion and backrest so the seat belt does not have to be used. Some automobiles have tether anchors for rear-facing infant-only seats as well. Although many infant restraints can be recliners, they are used in the car only in the position specified by the manufacturer.

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 for children. 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 is added to 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 from the hospital should be placed in an appropriate car seat restraint as it would be placed in the car and the infant’s heart rate and oxygen saturation monitored for a minimum of 1 hour and maximum of 3 hours (depending on the length of the trip to the home) to detect any potential problems with airway occlusion. (See Community Focus, p. 268, for preterm infant restraint; for further discussion of car seat restraints, see Chapter 12.)

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, and others, 2005). Falls are most common after 4 months of age when the infant has learned to roll over, but they can occur at any age. The best advice is never to place a child of any age unattended on a raised surface.

When in doubt, the safest place is the floor. Even though young infants cannot climb over a partially raised crib rail, it is best to form a habit of raising the rail all the way, since someday that infant will be able to climb out. Crib sides should have a latching device that cannot be easily released.

Another danger area for falling is the changing table, which is usually high and narrow. Although these tables have a restraining belt, children are never left unattended, even when restrained. The best way to avoid the need to leave the child unattended is to arrange the area with all necessary articles within easy reach so the child’s safety can be ensured. During the latter half of the first year, infants usually resist dressing and diapering and may be difficult to manage; therefore changing clothes may need to take place on a larger safe surface such as a clean floor.

Infant seats, high chairs, mobile walkers, and swings present additional opportunities for falls. If the infant seat is placed on a table, the child should never be left unrestrained or unattended. The same rule is essential for other baby equipment, particularly when the child has learned to crawl and to stand up. Small infants can slip through a high chair if a protective harness is not used. The danger of falls from being unrestrained also applies to shopping carts. High chairs are designed for older infants who can sit well and who are tall enough to have the tray at the level of their chest or abdomen.

Infant walkers (mobile) are responsible for a number of different types of injuries that occur because the walker tipped over or fell down stairs. Parents need to be warned of these dangers and encouraged to keep a constant vigil on their child’s activities. The American Academy of Pediatrics (2001a) does not recommend the use of mobile infant walkers. The use of older-model mobile walkers in particular should be discouraged. In response to the large number of accidents and deaths associated with infant walkers, several manufacturers modified these products to prevent falls down stairs. The new models should have a label or sign indicating “meets new safety standard,” must be wider than 36 inches, or must have a braking mechanism to stop the walker. Infant walkers may still pose a risk for climbing up to reach dangerous objects and should be carefully supervised. One alternative is to use a stationary play station with a seat similar to a walker. There is no evidence that infant walkers help infants walk sooner.

After 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. However, certain types of gates can present hazards. Freestanding enclosures constructed of crisscrossed wood slats that expand and contract can trap the head or neck when children attempt to climb over them. If these types of gates are used, they must be securely fastened to prevent mobility of the slats.

Even when the environment is made safe, infants may sometimes literally trip over their own feet from clothing. Slippery socks; hard, slick soles on shoes or rubber soles that can catch, especially on a carpet; and long pants or pajama bottoms can easily upset a child’s balance. Such dangers need to be pointed out to parents, especially when infants are taking their first steps.

An alarming number of small children fall out of windows and are hurt; this is especially common with windows such as bay windows that have wide ledges for children to sit on. Window screens should not be perceived as fall-prevention devices; rather, window guards should be installed to prevent falls from any window, regardless of the height. Furniture should be kept away from windows so children cannot climb onto the furniture and access the window.

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 danger of poisonous agents by virtue of immobility. However, after locomotion begins, danger from poisoning is present almost everywhere. There are more than 500 toxic substances in the average home, with approximately one third of all poisonings occurring 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. Drugs that are kept in a purse pose additional dangers; if the handbag is given to infants to play with, they may open it and ingest the drug. Another unrecognized hazard occurs during diaper changes, when infants are near many toxic substances such as ointments, creams, oils, and talc. 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).

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 have caused illness or death.

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. Inhalation is another possible route, such as inhaling chlorine vapors from household cleaning or pool supplies. 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 (by contact or ingestion) or during the production (cooking) of the drug itself. Methamphetamine laboratories are commonly located in household areas where children may be exposed to harmful inhalants; children are also at risk for burns from being in an area where methamphetamine is being cooked, since explosions are not uncommon. Children should be protected from environments in which inhaled toxins exist (for a discussion of passive or second-hand tobacco smoke, see Chapter 23).

The only sure 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 up all potentially toxic substances can present a problem; however, careful planning can help. A large surplus of cleaning agents, furniture polishes, laundry additives, paints, insecticides, and solvents should be avoided. Used poison containers should be promptly discarded and not used to store another poison without adequately marking the package. 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 location of local poison control centers and call them in the event of a suspected poisoning. Emergency measures for poisoning are discussed in Chapter 14.

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 water heater to a safe temperature of 49° C (120° F). In addition, the bathwater should be checked before the infant is immersed. 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 a temperature that is even higher. As a precaution, instruct caregivers to avoid bathing small children in the kitchen sink while the dishwasher is running.

If baby food is warmed in a microwave oven, it must be checked before feeding because the container may remain cool while the contents are hot. The handles of cooking pots should be turned toward the back of the stove. When the infant is underfoot, pouring hot liquids and cooking with hot oil are avoided. Hanging tablecloths are also placed out of the infant’s reach to prevent pulling hot items off the table.

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 younger than 6 months (see Sunburn, Chapter 30). Although dark-skinned infants burn less readily, their thin skin also 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 objects such as hairpins 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 placed 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 must never be viewed as 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, parents are advised 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. Parents are cautioned to never leave children in parked cars if the outside ambient temperature is above 27° C (80° F). A significant number of childhood deaths occur annually when a child is left unattended in a vehicle.

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 two of water. Consequently, infants should always be supervised in a bathtub or near a source of water such as a swimming pool, lake, toilet, or bucket. In a survey of drownings most infants younger than age 1 year drowned in a toilet, bathtub, or bucket (Lassman, 2002); 5-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, be unable to withdraw from the bucket. Organized swimming instruction is not recommended for children younger than 4 years of age because it may lead to a false sense of security. No infant can be expected to learn the elements of water safety or to 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 articles, such as the common 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, small articles can be placed 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.

As children begin to pull themselves to a standing position, heavy objects, such as unsturdy furniture or any freestanding item (e.g., wrought iron fish tank stands, stereo equipment, or television), can be extremely dangerous if pulled down on top of the child. To prevent injury from furniture tipping over, televisions should be placed on lower furniture and as far back as possible. Angle braces or anchors can secure furniture to walls.

Even clothes and hair can present dangers to infants who cannot call attention to the problem. For example, constriction injuries can occur from excessively tight bands on socks or strands of hair or thread wrapped tightly around appendages, usually toes or fingers.

An alarming trend is the increasing number of infant deaths attributed to homicide. In one study 6.4% of 10,370 infant injury deaths occurred as a result of homicide (Brenner, Overpeck, Trumble, and others, 1999). Infant deaths that were previously attributed to SIDS now may be found to occur as a result of intentional harm. Specific interventions must be in place to protect infants from harm, especially in preventable situations.

Another commonly unrecognized danger to infants is animal attacks. As newcomers to the home, infants can provoke jealousy in animals such as dogs or cats or play with pets, unaware of the danger. Parents must be vigilant to protect the child from household pets and farm animals (see Animal Bites, Chapter 30).

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, and others, 2005; Schnitzer, 2006). 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 10-1) 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 the importance of safety cannot be overemphasized. The Family-Centered Care box summarizes a home safety checklist that can be presented to parents to increase their awareness of danger areas in the home and assist them in implementing safety devices and practices before their absence can inflict injury on infants. 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.

Injury prevention requires protection of the child and education of the caregiver. Nurses in ambulatory care settings, health maintenance centers, 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 as an excellent opportunity for discussing this topic. Although early postpartum discharge may be restrictive for parent teaching, this is an excellent opportunity to introduce the family to infant safety and safety for other children as well. Parents should be encouraged to take an infant cardiopulmonary resuscitation (CPR) class to deal effectively with potential problems. This tool further empowers the parents to raise their new infant in the best environment possible.

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 the why of the injury. However, injury prevention must also be practical. Asking parents for their ideas leads to realistic suggestions that can be followed. For instance, bathroom cleaning agents, cosmetics, and personal care items can be placed on a top shelf in the linen closet, and towels or sheets can be stored on the lower shelves and floor.

If an injury has occurred, the nurse should not be too quick to admonish the parent. Injuries do not always indicate neglect. It is a difficult task to watch children carefully without overprotecting or unnecessarily confining them. Small falls help children learn the dangers of heights. Touching a hot object once can emphasize to the child the pain of a burn. Allowing children to explore while maintaining consistent, age-appropriate limits is sound advice.

Parents need to remember that infants and young children cannot anticipate danger or understand when it is or is not present. Additionally, infants have no cognitive concept of cause and effect and therefore cannot relate meaning to experiences or potential dangers. A dead electrical wire may present no actual harm, but if the child is allowed to play with it, a poor behavior is enforced and will be practiced when the child encounters a live wire. Although it is always wise to explain why something is dangerous, it must be remembered 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. Preventing injuries to children 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, dangerous objects must be removed or guarded and valuable articles placed out of reach.

When children are taught the meaning of “no,” they should also be taught what “yes” means. Children should be praised for playing with suitable toys, their efforts at behaving or listening should be reinforced, and innovative and creative recreational toys should be provided 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, parents should provide child-safe books (such as those constructed of fabric) 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. Practicing safety teaches safety, which 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.

Academy of Breastfeeding Medicine. Clinical protocol: guideline on co-sleeping and breastfeeding. http://www.bfmed/org/ace-files/protocol/cosleeping.pdf, 2003. [The Academy, retrieved Jan 1, 2007 from].

Agran, PF, Anderson, C, Winn, D, et al. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics. 2003;111(6):e683–e692.

American Academy of Pediatric Dentistry. Guideline on infant oral health care. In AAPD Reference Manual 2005-2006. http://www.aapd.org/media/Policies_Guidelines/G_InfantOralHealthCare.pdf. [retrieved Jan 1, 2008, from].

American Academy of Pediatrics, Committee on Infectious Diseases. Recommended immunization schedule for children and adolescents—United States, 2007. Pediatrics. 2007;119(1):207–208.

American Academy of Pediatrics. Dietary recommendations for children and adolescents: a guide for practitioners. Pediatrics. 2006;117(2):544–559.

American Academy of Pediatrics, Committee on Infectious Diseases, Pickering L, eds. Red book: 2006 report of the Committee on Infectious Diseases, ed 27, Elk Grove Village, Ill: The Academy, 2006.

American Academy of Pediatrics, Committee on Infectious Diseases. Recommended immunization schedules for children and adolescents—United States, 2008. Pediatrics. 2008;121(1):219–220.

American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116(5):1245–1255.

American Academy of Pediatrics, Committee on Nutrition. Pediatric nutrition handbook, ed 5. Elk Grove Village, Ill: The Academy, 2004.

American Academy of Pediatrics. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics. 2003;111(4):908–910.

American Academy of Pediatrics, Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics. 2001;108(3):790–792.

American Academy of Pediatrics, Committee on Nutrition. The use and misuse of fruit juice in pediatrics. Pediatrics. 2001;107(5):1210–1213.

American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3):650–656.

American Dental Association. For the dental patient … infants, formula and fluoride. J Am Dent Assoc. 2007;138(1):132.

American Psychiatric Association Reactive attachment disorder (position statement) Washington, DC: The Association; 2002. retrieved June 2007 from http://www.psych.org/edu/other_res/lib_archives/archives/200205.pdf

Anderson, JE. “Nothing but the tooth”: dispelling myths about teething. Contemp Pediatr. 2004;21(7):75–83.

Ball, HL. Breastfeeding, bed sharing, and infant sleep. Birth. 2003;30(3):181–188.

Barnhill, BJ, Holbert, MD, Jackson, NM, et al. Using pressure to decrease the pain of intramuscular injections. J Pain Symptom Manage. 1996;12(1):52–58.

Biancuzzo, M. Breastfeeding the newborn: clinical strategies for nurses, ed 2. St Louis: Mosby, 2003.

Brady, MT. Infectious disease in pediatric out-of-home child care. Am J Infect Control. 2005;33(5):276–285.

Brazelton, T. Parent-infant cosleeping revisited. Brazelton Center Newslett. 2, 1990.

Brenner, RA, Overpeck, MD, Trumble, AC, et al. Deaths attributable to injuries in infants, United States, 1983-1991. Pediatrics. 1999;103(5):968–974.

Calamaro, CJ. Infant nutrition in the first year of life: tradition or science? Pediatr Nurs. 2000;26(2):211–215.

Carroll-Pankhurst, C, Mortimer, EA. Sudden infant death syndrome, bedsharing, parental weight, and age at death. Pediatrics. 2001;107(3):530–536.

Carey, WB, McDevitt, SC. Revision of the infant temperament questionnaire. Pediatrics. 1978;61(5):735–739.

Centers for Disease Control and Prevention. Fatal injuries among children by race and ethnicity—United States, 1999-2002. MMWR. 2007;56(SS-5):1–16.

Centers for Disease Control and Prevention. Quadrivalent human papillomavirus vaccine. MMWR. 2007;56(RR-2):1–24.

Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization. MMWR. 2006;55(RR-7):1–23.

Centers for Disease Control and Prevention. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. MMWR. 2006;55(RR-17):1–33.

Centers for Disease Control and Prevention. Update: Guillain-Barré syndrome among recipients of Menactra meningococcal conjugate vaccine—United States, June 2005–September 2006. MMWR. 2006;55(41):1120–1124.

Centers for Disease Control and Prevention. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR. 2005;54(RR-16):1–23.

Centers for Disease Control and Prevention. Nonfatal motor-vehicle-related backover injuries among children—United States, 2001-2003. MMWR. 2005;54(06):144–146.

Centers for Disease Control and Prevention. Outbreaks of pertussis associated with hospitals—Kentucky, Pennsylvania, and Oregon, 2003. MMWR. 2005;54(03):67–71.

Chung, JWY, Ng, WMY, Wong, TKS. An experimental study on the use of manual pressure to reduce pain in intramuscular injections. J Clin Nurs. 2002;11:457–461.

Dahl, RE. The development and disorders of sleep. Adv Pediatr. 1998;45:73–90.

Davis, KF, Parker, K, Montgomery, GL. Sleep in infants and young children, part 2, Common sleep problems. J Pediatr Health Care. 2004;18(3):130–137.

Dewey, KG. Nutrition, growth, and complementary feeding of the breastfed infant. Pediatr Clin North Am. 2001;48(1):87–104.

Diggle, L, Deeks, J. Effect of needle length on incidence of local reactions to routine immunizations in infants aged 4 months: randomized controlled trial. BMJ. 2000;321(7266):931–993.

Diggle, L, Deeks, JJ, Pollard, AJ. Effect of needle size and immunogenicity and reactogenicity of vaccines in infants: a randomized controlled trial. BMJ. 2006;333(7568):571.

Douglass, JM, Douglass, AB, Silk, HJ. A practical guide to infant oral health. Am Fam Physician. 2004;70(11):2113–2120.

Drago, DA, Dannenberg, AL. Infant mechanical suffocating deaths in the United States, 1980-1997. Pediatrics. 1999;103(5):e59.

Duro, D, Rising, R, Cedillo, M, et al. Association between infantile colic and carbohydrate malabsorption from fruit juices in infancy. Pediatrics. 2002;109(5):797–805.

Ferber, R, Kryger, M. Principles and practice of sleep medicine in the child. Philadelphia: Saunders, 1995.

Fiocchi, A, Assa’ad, A, Bahna, S, et al. Food allergy and the introduction of solid foods to infants: a consensus document. Ann Allergy Asthma Immunol. 2006;97(1):10–20.

Fox, MK, Reidy, K, Novak, T, et al. Sources of energy and nutrients in the diets of infants and toddlers. J Am Diet Assoc. 2006;106(1 Suppl 1):S28–S42.

Fredrickson, DD, Davis, TC, Arnold, CL, et al. Childhood immunization refusal: provider and parent perceptions. Fam Med. 2004;36(6):431–438.

Grummer-Strawn, LM, Mei, Z, Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics. 2004;113(2):e81–e86.

Halperin, BA, Halperin, SA, McGrath, P, et al. Use of lidocaine-prilocaine patch to decrease intramuscular injection pain does not adversely affect the antibody response to diphtheria–tetanus–acellular pertussis–inactivated poliovirus–Haemophilus influenzae type b conjugate and hepatitis B vaccines in infants from birth to 6 months of age. Pediatr Infect Dis. 2002;21(5):399–405.

Hauck, FR, Herman, SM, Donovan, M, et al. Sleep environment and the risk of sudden infant death syndrome in an urban population: the Chicago Infant Mortality Study. Pediatrics. 2003;111(5 part 2):1207–1214.

Hawkins-Walsh, E. A behavioural infant sleep intervention resolved sleep problems. Evidence-Based Nurs. 2003;6(1):10–12.

Henary, B, Sherwood, CP, Crandall, JR, et al. Car safety for children: rear facing for best protection. Inj Prev. 2007;13(6):398–402.

Heron, J, Golding, J, ALSPAC Study Team. Thimerosal exposure in infants and developmental disorders: a prospective cohort study in the United Kingdom does not support a causal association. Pediatrics. 2004;114(3):577–583.

Hiscock, H, Wake, M. Infant sleep problems and postnatal depression: a community-based study. Pediatrics. 2001;107(6):1317–1322.

Horn, MI, McCarthy, AM. Children’s responses to sequential versus simultaneous immunization injections. J Pediatr Health Care. 1999;13(1):18–23.

Ize-Ludlow, D, Ragone, S, Bruck, IS, et al. Neurotoxicities in infants seen with the consumption of star anise tea. Pediatrics. 2004;114(5):e653.

Joanna Briggs Institute. Evidence based practice information sheet for health professionals: early childhood pacifier use in relation to breastfeeding, SIDS, infection, and malocclusion. Best Practice. 2005;9(3):1–6.

Koslap-Petraco, MB, Parsons, T. Communicating the benefits of combination vaccines to parents and health care providers. J Pediatr Health Care. 2003;17(2):53–57.

Lassman, J. Water safety. J Emerg Nurs. 2002;28(3):241–243.

Lawrence, RA, Lawrence, RM. Breastfeeding: a guide for the medical profession, ed 6. St Louis: Mosby, 2005.

Lee, MS, Bernstein, HH. Immunizations, neonatal jaundice and animal-induced injuries. Curr Opin Pediatr. 2005;17(3):418–429.

Loman, DG. The use of complementary and alternative health care practices among children. J Pediatr Health Care. 2003;17(2):58–63.

Macknin, ML, Piedmonte, M, Jacobs, J, et al. Symptoms associated with infant teething: a prospective study. Pediatrics. 2000;105(4):747–752.

Martin, J, Hiscock, H, Hardy, P, et al. Adverse associations of infant and child sleep problems and parent health: an Australian population study. Pediatrics. 2007;119(5):947–955.

Martin, JA, Kochanek, KD, Strobino, DM, et al. Annual summary of vital statistics—2003. Pediatrics. 2005;115(3):619–634.

McGarvey, C, McDonnell, M, Chong, A, et al. Factors relating to the infant’s last sleep environment in sudden infant death syndrome in the Republic of Ireland. Arch Dis Child. 2003;88(12):1058–1064.

Medoff-Cooper, B, Carey, WB, McDevitt, SC. The early infancy temperament questionnaire. J Dev Behav Pediatr. 1993;14(4):230–235.

Mell, LK, Ogren, DS, Davis, RL, et al. Compliance with national immunization guidelines for children younger than 2 years, 1996-1999. Pediatrics. 2005;115(2):461–468.

Mesich, HM. Mother-infant co-sleeping: understanding the debate and maximizing infant safety. MCN. 2005;30(1):30–37.

Morin, K. Infant nutrition: what about water softeners and bottled water for babies? MCN. 2007;32(1):57.

Moukarzel, AA, Lesicka, H, Ament, ME. Irritable bowel syndrome and nonspecific diarrhea in infancy and childhood—relationship with juice carbohydrate malabsorption. Clin Pediatr. 2002;41(3):145–150.

Narendran, V, Hoath, SB. The skin. In Martin RJ, Fanaroff AA, Walsh MC, eds.: Fanaroff and Martin’s neonatal-perinatal medicine, ed 8, St Louis: Mosby, 2006.

Niggemann, B, Grüber, C. Side-effects of complementary and alternative medicine. Allergy. 2003;58(8):707–716.

Parker, SK, Schwartz, B, Todd, J, et al. Thimerosol-containing vaccines and autistic spectrum disorder: a critical review of published original data. Pediatrics. 2004;114(3):793–804.

Patterson, DL. Adolescent-mothering: child-grandmother attachment. J Pediatr Nurs. 1997;12(4):228–237.

Person, TL, Lavezzi, WA, Wolf, BC. Cosleeping and sudden unexpected death in infancy. Arch Pathol Lab Med. 2002;126(3):343–345.

Phelan, KJ, Khoury, J, Kalkwarf, H, et al. Residential injuries in U.S. children and adolescents. Pub Health Rep. 2005;120(1):63–70.

Pickett, W, Streight, S, Simpson, K, et al. Injuries experienced by infant children: a population-based epidemiological analysis. Pediatrics. 2003;111(4 pt 1):e365–e370.

Pinelli, J, Symington, A, Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev 2000;2:CD001071.

Pinelli, J, Symington, A, Ciliska, D. Nonnutritive sucking in high-risk infants: benign intervention or legitimate therapy? J Obstet Gynecol Neonatal Nurs. 2002;31(5):582–591.

Quillin, SI, Glenn, LL. Interaction between feeding method and co-sleeping on maternal-newborn sleep. J Obstet Gynecol Neonatal Nurs. 2004;33(5):580–588.

Reis, EC, Holubkov, R. Vapocoolant spray is equally effective as EMLA cream in reducing immunization pain in school-aged children. Pediatrics. 1997;100(6):1025.

Rojjanasrirat, W. Working women’s breastfeeding experiences. MCN. 2004;29(4):222–227.

Schachter, F, Fuchs, ML, Bijer, PE, et al. Cosleeping and sleep problems in Hispanic-American urban young children. Pediatrics. 1989;84(3):522–530.

Schack-Nielsen, L, Michaelsen, KF. Breast feeding and future health. Curr Opin Nutr Metab Care. 2006;9(3):289–296.

Schechter, NL, Zempsky, WT, Cohen, LL, et al. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics. 2007;119(5):e1184–e1198.

Schnitzer, PG. Prevention of unintentional childhood injuries. Am Fam Physician. 2006;74(11):1864–1869.

Schuval, S. Avoiding allergic reactions to childhood vaccines (and what to do when they occur). Contemp Pediatr. 2003;22(4):29–49. [53,].

Stevens, B, Johnston, C, Franck, L, et al. The efficacy of developmentally sensitive interventions and sucrose for relieving procedural pain in very low birth weight neonates. Nurs Res. 1999;48(1):35–43.

Stevens, B, Yamada, J, Ohlsson, A, Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev 2001;4:CD001069.

Sullivan, JR. Development of father-infant attachment in fathers of preterm infants. Neonatal Netw. 1999;18(7):33–39.

Tappin, D, Ecob, R, Brooke, H. Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: a case-controlled study. J Pediatr. 2005;147(1):32–37.

Thompson, DG. Utilizing an oral sucrose solution to minimize neonatal pain. J Spec Pediatr Nurs. 2005;10(1):3–10.

Touchette, E, Petit, D, Paquet, J, et al. Factors associated with fragmented sleep at night across early childhood. Arch Pediatr Adolesc Med. 2005;159(3):242–249.

US Food and Drug Administration, FDA approves new vaccine to prevent rotavirus gastroenteritis in infants. FDA News. The Administration: Rockville, Md, 2006. retrieved Jan 1, 2008, from http://www.fda.gov/bbs/topics/news/2006/NEW01307.html

Wall, EJ. Practical primary pediatric orthopedics. Nurs Clin North Am. 2000;35(1):95–113.

Wilkerson, R, Northington, LD, Fisher, W. Ingestion of toxic substances by infants and children: what we don’t know can hurt. Crit Care Nurs. 2005;25(4):35–44.

Willinger, M, Ko, CW, Hoffman, HJ, et al. Trends in infant bed sharing in the United States, 1993-2000: the National Infant Sleep Position study. Arch Pediatr Adolesc Med. 2003;157(1):33–39.

Wilson, ME, White, MA, Cobb, B, et al. Family dynamics, parental-fetal attachment and infant temperament. J Adv Nurs. 2000;31(1):204–210.

Wilson, S. Attachment disorders: review and current status. J Psychol. 2001;135(1):37–51.

Wong, DL. Topical local anesthetics: two products for pain relief during minor procedures. Am J Nurs. 2003;103(6):42–45.

Zeanah, CH, Fox, NA. Temperament and attachment disorders. J Clin Child Adolesc Psychol. 2004;33(1):82–87.

Zuckerman, JN, Cockcroft, A, Zuckerman, AJ. Site of injection for vaccination. BMJ. 1992;305(6862):1158.

Zuckerman, J. The importance of injecting vaccines into muscle. BMJ. 2000;321(7271):1237–1238.