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Assisting in Pediatrics
Chapter 42
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Learning Objectives
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Define, spell, and pronounce the terms
listed in the vocabulary.
Apply critical thinking skills in performing
patient assessment and care.
Describe childhood growth patterns.
Summarize the important features of the
Denver II Developmental Screening Test.
Identify four different growth and
development theories.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Learning Objectives
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Explain common pediatric gastrointestinal
disorders and their signs, symptoms, and
treatments.
Classify disorders of the respiratory system in
children.
Distinguish among pediatric infectious diseases.
Recognize the etiologic factors and signs and
symptoms of the two primary pediatric inherited
disorders.
Summarize CDC-recommended immunizations
for children.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
3
Learning Objectives
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Demonstrate how to document and maintain
accurate immunization records.
Compare and contrast a well-child and a
sick-child examination.
Outline the medical assistant’s role in a
pediatric examination.
Measure the circumference of an infant’s
head.
Obtain accurate length and weight
measurements, and plot pediatric growth
patterns.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
4
Learning Objectives
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Accurately measure pediatric vital signs
including vision screening.
Correctly apply a pediatric urine collection
device.
Specify child safety guidelines for injury
prevention and management of suspected
child abuse.
Describe the characteristics and needs of the
adolescent patient.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
5
Normal Growth and Development
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Growth—measurable changes such as height
and weight.
Development—maturing in motor, mental, and
language.
Compare the child’s physical, intellectual, and
social levels with national standards to
determine if the child’s maturation is age
appropriate.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
6
Growth Patterns
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Infant’s birth weight should double by 6 months of age
and triple by 1 year, with length increasing by 50%.
By age 2 years the child is at 50% of his or her adult
height.
By 4 years the child has doubled his or her birth length.
Child has a growth spurt around age 12 years heading
into adolescence.
When the growth spurt ends the child has reached
sexual maturity with the onset of menstruation in
females and sperm in the semen for males.
Skeletal growth is completed with fusion of the
epiphyseal plates.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
7
Therapeutic Approaches for Infants
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Crying is normal; use distraction to help
Parent should hold infant if possible
Involve the parent as much as possible
Place a familiar object near the infant
Making strange starts around 8 months; do not
take rejection personally
Do not restrain infant any more than necessary
Encourage caregiver to comfort child after
procedures
Unpleasant procedures are associated with
objects; offer favorite toy afterward for comfort
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
8
Therapeutic Approaches for Toddlers
and Preschoolers
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Often fear doctor visits; ignore temper tantrums and
negative behavior
Praise child as much as possible
Perform unpleasant procedures as quickly as possible
Keep as much clothing on as possible for security and
comfort
Use words the child is familiar with, and avoid those that
they could misinterpret
Explain procedures as the child would sense them
Allow the child to handle equipment when possible
Do not use the child’s favorite doll or stuffed animal to
demonstrate; the child may believe the toy feels pain.
Explain procedures to the parents away from the child
when possible
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
9
Therapeutic Approaches
for School-Aged Children
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Allow choices when possible
Parent should be present during examinations
Remove only as much clothing as needed
Explain procedures in concrete terms; use pictures
and diagrams
Give child time to ask questions
Children are often curious and cooperative if they
know what is expected
Address the conversation to the child; involve the
child in decision making as much as possible
Provide privacy
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Therapeutic Approaches for
Adolescents
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Adolescent is self-conscious and strongly
influenced by peers
Privacy is very important
Address how a procedure might affect appearance
Do not be judgmental; listen without condemning
Encourage teens to verbalize concerns and fears
May regress to more childish behaviors when sick
Teens want to be treated like adults; want to know
what is being done and why
Encourage teens to see physician without parents
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11
Critical Thinking Application
What would be the best way to deal with the following patient
situations?
 A crying 3-month-old baby being seen today for a
well-child visit
 A 10-month-old baby with otitis media
 A 2-year-old child who has to have a wound dressing
changed
 A 5-year-old child ordered vision and hearing screening
 An 8-year-old child ordered a throat culture
 A 12-year-old child ordered a penicillin injection in the
dorsogluteal site
 A 15-year-old female patient with complaints of abdominal
pain who is accompanied by her mother
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12
Denver II Developmental Screening
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A standardized evaluation tool that should be done
at 3 to 4 months, again at 10 months, again at
3 years.
If results are abnormal, child should be tested by
professionals.
Assesses:
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Gross motor skills—standing, kicking, running,
balance
Language—evaluate word comprehension, ability to
follow commands, counting
Fine motor adaptive skills—reaching, grasping, piling
blocks, drawing
Personal skills—playing games, using utensils,
dressing
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13
Developmental Stages
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Occurs rapidly through infancy; by age 3 years there is
increased autonomy; vocabulary of up to 900 words.
Preschool—increasingly independent, initiates
activities; has mastered gross motor activities; forms
complete sentences; will take all statements literally;
needs to work on social skills such as sharing.
School-age—perfected fine-motor skills; intellectual
skills developing; developing sense of self-worth;
testing social skills away from the family.
Adolescent—working at adult identity through
experimentation; peers most important influence;
risk-taking behaviors common.
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14
Pediatric Examination Guidelines:
Infant and Toddler
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Have a “fun” basket of distracters available.
If giving rewards, give them to all children.
Offer the choice of whether the parent is
present.
Make sure child is in a safe position and
environment at all times.
Tell child when the procedure is done.
Have extra supplies handy just in case more
are needed or originals are contaminated.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
15
Examination Guidelines:
School-Aged Child
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Determine knowledge about terminology and
procedures.
Allow child time to ask questions.
Prepare child for the procedure.
Teach simple relaxation techniques such as
deep breathing and focusing on something fun.
Give the child the responsibility for simple
tasks—helping take off a bandage or picking
out a new one, choosing which leg gets the
injections, etc.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
16
Examination Guidelines: Adolescent
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Give child as much control as possible.
Let child decide if parent will be present.
Explain medications, procedures, diagnostic
studies so child understands.
Make sure child understands if the procedure
will affect appearance and how.
If procedure will produce a scar, discuss how
scar formation can be minimized.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
17
General Guidelines
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Use older siblings when possible.
Allow the child to handle equipment when
possible.
Use games to get cooperation—Simon Says,
drawing on examination table paper, etc.
Proceed from the least to the most invasive or
painful procedure.
Talk through the procedure to both child and
parent.
Allow choices for the older child.
Praise and give rewards.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
18
Environmental Guidelines
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Never turn away from a child who is on the
examination table.
Safeguard the examination and waiting rooms.
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No medications in the room.
 Keep equipment secured behind protected
cupboards.
 Warn against climbing on furniture and using the
physician’s wheeled chair.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
19
Developmental Theories: Table 42-1
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Sigmund Freud
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Erik Erikson
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Unconscious mind, id, ego, and superego
Trust versus mistrust; autonomy versus shame and
doubt; initiative versus guilt; industry versus
inferiority; identity versus role confusion
Piaget’s developmental theory
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Sensorimotor stage, preoperational stage, concrete
operational stage, formal operational stage
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20
Developmental Theories
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Kohlberg
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Preconventional morality
 Conventional level
 Postconventional level
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21
Pediatric Diseases and Disorders:
Gastrointestinal Disorders
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Colic
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Condition occurring in an infant between 2 weeks
and 4 months of age with crying episodes that occur
at least three times a week for greater than 3 hours
a day and lasting 3 weeks.
The infant draws up the legs, clenches the fists, and
cries inconsolably.
Diarrhea
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Caused by variety of microorganisms or allergies.
Diagnosed when the child has two or more watery
or apparently abnormal stools within a 24-hour
period.
Dehydration.
Fluids, BRAT diet, antidiarrheal medications.
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22
Failure to Thrive
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An infant or young child whose weight is
consistently below the third percentile on
standardized growth charts or one who is
20% below the ideal body weight for length.
Physical, mental, and social skills are also
delayed.
Accurately document weight, height, and head
circumference.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
23
Obesity
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Plot the child’s BMI-for-age.
It is estimated that more than 30% of
school-aged children are overweight, and
almost 20% are considered obese.
Family history of obesity, inactivity, high-calorie
diets, stress, endocrine or metabolic disorders.
At risk for developing asthma, type 2 diabetes,
sleep apnea, hypercholesterolemia,
cardiovascular disease, and hypertension.
Psychosocial impact.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
24
Respiratory Disorders
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Common cold or infectious rhinitis
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Signs include nasal congestion, low-grade fever,
and general malaise.
Self-limiting.
Secondary infections.
Otitis media
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Infection or inflammation of the middle ear.
Signs and symptoms: inflammation of the middle
ear, fluid buildup, crying, tugging at the ear, fever,
irritable, and have decreased hearing in the
affected ear.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
25
Otitis Media
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Serous otitis media.
From Swartz MH: Textbook of physical diagnosis, ed 5, Philadelphia, 2006, Saunders;
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Suppurative otitis media.
Courtesy Dr. Richard A. Buckingham and Dr. George E. Shambaugh, Jr.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
26
Otitis Media Treatment
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Traditionally treated with antibiotics
If viral infection antibiotics will not help
Recommendations have changed because of
antibiotic-resistance concerns:
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Acetaminophen or ibuprofen for pain or fever
Delay antibiotics for 48 to 72 hours
Children 6 to 24 months old without improvement
in 24 hours or children older than 24 months in
72 hours prescribed antibiotics
Medication ordered for 5 days
Myringotomy for repeat infections
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
27
Respiratory Disorders
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Croup
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Viral inflammation of the larynx and the trachea just
beneath it that causes edema and spasm of the
vocal cords
Bronchiolitis
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Viral infection of the small bronchi and bronchioles
that usually affects children under 3 years of age
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28
Asthma
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Bronchospasm and inflammation.
Many factors can trigger an asthma attack.
Signs and symptoms: nonproductive cough,
expiratory wheeze, shortness of breath,
difficulty speaking, tightness or pressure in the
chest.
Treatment: inhaled corticosteroids, rescue
bronchodilators, and oral medications.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
29
Influenza
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Acute, highly contagious viral infection of the
respiratory tract.
Usual treatment for influenza is bed rest,
increased fluids, and a nonaspirin analgesic to
reduce fever and relieve discomfort.
Some drugs can shorten the duration of the flu
but must be taken at onset of symptoms
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Inhaled Relenza and oral oseltamivir (Tamiflu)
Antibiotics are prescribed only if there is a
secondary bacterial infection
Flu vaccines for prevention
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30
Conjunctivitis
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Highly contagious
Caused by bacterial or viral infection
Produces white or yellowish pus
Health teaching for caregivers:
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Use good hand sanitization practices and hygiene
Do not share towels or any other item
Disinfect any contaminated articles
Should be treated for at least 24 hours before
returning to day care or school
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
31
Tonsillitis
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Tonsillitis
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Usually caused by Streptococcus A
Tonsils appear enlarged and inflamed and may be
covered with pustules
Treatment – bed rest, liquid to soft diet, analgesic
throat spray, and oral antibiotics
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32
Fifth Disease
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Erythema infectious, parvovirus infection, or
slapped cheek disease
Symptoms – mild fever, general malaise,
flushed cheeks, lacy rash on trunk, arms,
and legs
Typically recover without any serious
consequences
Pregnant women – increased risk of
miscarriage and fetal anemia
Spread through direct contact
Most contagious before onset of rash
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33
Hand-Foot-and-Mouth Disease
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Caused by coxsackievirus
Seen most often in day care settings
Symptoms – fever; sore throat; painful red blisters on
the tongue, mouth, palms of the hands, and soles of
the feet; headache; anorexia, and irritability
Dehydration can occur – stop eating and drinking
because of painful sores in the mouth
Antibiotic therapy is not helpful so the disease must
run its course
To prevent spread wash hands thoroughly, especially
after diaper changes, and disinfect shared items
Should be kept out of day care or school until fever is
gone and mouth sores healed
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34
Varicella (Chicken Pox)
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Caused by a herpesvirus group; transmitted
by direct or indirect droplets from the
respiratory tract; incubation period is 14 to
21 days
After infection the virus migrates to a
dermatome and may cause “shingles” or
herpes zoster
Varicella virus vaccine, Varivax – two
doses – first between 12 and 15 months;
second between 4 and 6 years
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35
Meningitis
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Inflammation of the membranes that cover
the brain and spinal cord
Viral meningitis – usually mild; clears up on
its own within 10 to 14 days
Fungal meningitis – serious for AIDS patients
Bacterial meningitis – most serious types
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Neisseria meningitis – meningococcal meningitis
Streptococcus pneumoniae
Haemophilus influenzae – Hib vaccine
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36
Reye’s Syndrome
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Linked to the use of aspirin during a viral
illness
Causes liver and brain involvement
Signs and symptoms: may progress through
five stages: restlessness, vomiting, liver
dysfunction, elevated respiratory rate,
hyperactive reflexes, coma, seizures,
respiratory arrest, and death
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37
Critical Thinking Application

A father of a 10-year-old girl calls this
morning concerned about his daughter’s
symptoms. She has a sore throat, fever, and
bright red cheeks. He wants to give her
aspirin for the fever. What advice should
Susie give the father? What questions should
she ask to determine the seriousness of the
child’s problem? Should she list this call on
the physician's call back list?
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38
Inherited Disorders
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Cystic fibrosis
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Autosomal recessive genetic disorder.
Lungs and pancreas are primarily affected, causing
a buildup of abnormally thick secretions.
Signs and symptoms: salty taste to the skin,
steatorrhea, abdominal distention, failure to thrive,
chronic cough, and frequent respiratory infections.
Diagnosis – Sweat test reveals elevated chlorine
level
Treatment – prevent bronchial obstruction with
chest percussion, bronchodilators, antibiotics for
signs of infection, and Pulmozyme; pancreatic
enzymes to improve digestion and absorption of
nutrients
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39
Duchenne’s Muscular Dystrophy
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X-linked genetic disease that causes progressive
muscle degeneration
Usually develops before age 5 years, with
muscular weakness, frequent falls, waddling gait,
possible swallowing problems, and difficulty
climbing stairs
Diagnosis – CPK level, electromyography, and
muscle biopsy
Respiratory insufficiency and infections are
common because of involvement of the diaphragm
and intercostal muscles required for breathing
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40
Autism
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Autism screening recommended for all children by age
2 years
Three to six children out of every 1,000 are diagnosed
with autism; four times more common in male children
Cause unknown; believed due to a combination of genetic
errors and environmental factors, perhaps a problem with
fetal brain development
Extensive studies have failed to show link with
vaccinations
Children have impaired social interaction, do not respond
to their name, avoid eye contact, show limited interest in
their surroundings, rarely communicate with others,
display repetitive movements or mannerisms such as
rocking or twirling, may have self-abusive behaviors
Treatment – coordinated educational and behavioral
interventions
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41
Guidelines for Childhood
Immunizations
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
42
Vaccine Information Sheets
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VIS provides information about risks and
benefits of each vaccine.
Parent given most current VIS before vaccine
administered
Documentation – date VIS given and
publication date of the VIS
Most current VIS forms available through
state health department or refer CDC site at
www.cdc.gov/nip/publications/VIS/default.htm
Informed consent must be signed before
immunizations are given
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43
Vaccine Information Sheets
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Documentation – date administered, vaccine
manufacturer, manufacturer’s lot number,
type of vaccine, exact site of injection, side
effects, name and title of person
administering, and facility address
Complete parent’s immunization booklet each
time child receives vaccination
Vaccine vials must be handled and stored
properly
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44
Checklist for Safe Vaccine Handling
and Storage
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One person in charge of handling and storage of
vaccines
Vaccine inventory log maintained that includes the
following:
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Vaccine name, number of doses, and date received
Condition of vaccine on arrival
Vaccine manufacturer, lot number, and expiration date
Full-size refrigerator for vaccine storage with
separate freezer compartment door
Vaccine refrigerator used for food or drinks
Store vaccines in middle of refrigerator; NOT on door
Use vials with nearest expiration date first
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45
Checklist for Safe Vaccine Handling
and Storage
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Sign posted identifying which vaccines should be
stored in either the refrigerator or freezer
Thermometer in the refrigerator and freezer;
refrigerator temperature maintained at 35–46ºF
(2–8ºC) and freezer at +5ºF (–15ºC) or colder
Containers of water kept in refrigerator and ice
packs in freezer to help maintain cold
temperatures
Maintain a temperature log
“Do Not Unplug” sign next to refrigerator’s
electrical outlet
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46
Critical Thinking Application

Susie will be administering pediatric immunizations
during well-baby visits scheduled for today. To
prepare for this responsibility, Susie looked up the
primary vaccinations, their routes of administration,
contraindications, and possible side effects. The
first child is here for her 4-month checkup. What
immunizations should the child receive and how
should they be administered? The baby’s father
asks if she will get sick from the vaccines. What
should Susie tell him? What does Susie need to do
to meet the requirements of the national childhood
vaccine injury act?
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47
Apgar Score
Newborn evaluation of well-being done at 1 minute
and at 5 minutes after birth evaluates the following,
with a potential score of 2 points for each item for a
possible total of 10 points. Refer to Table 42-4.
 Heart rate
 Respiratory effort
 Muscle tone
 Reflex irritability
 Color or appearance
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48
Well-Child Visits
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The frequency of well-child visits varies with
the physician and the community.
 2 weeks, 4 weeks, 8 weeks, 4 months,
6 months, 12 months, 18 months, 2 years,
5 years, 10 years, and 15 years
Visits focus on maintaining the health of the
child through basic system examinations,
immunizations, and upgrading of the child’s
medical history record.
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49
Sick-Child Visits
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Appointments are as needed.
Some criteria to consider when conducting
telephone screening include:
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If the child is young (less than 2 years old) and the
parent reports frequent cycles of crying, lethargy,
vomiting longer than 24 hours, diarrhea (more than
six stools in the last 12 hours), or fever of 101°F
(38.5°C) or higher, it is best to see the child right
away. He or she cannot verbalize associated pain or
problems.
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50
Medical Assistant’s Role in Pediatric
Procedures
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Assisting the pediatrician with examinations
Upgrading patient histories
Performing ordered screening tests such as
vision, hearing, urinalysis, and hemoglobin
checks
Administering immunizations
Measuring and weighing children as needed
Providing patient and caregiver support
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51
Measurement
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The medical assistant should record the child’s
length or height, weight, and head
circumference on growth charts so the
physician can compare the child’s
measurement statistics with national
standards.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
52
Assisting with the Examination:
Pediatric Weight
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The dose of medication prescribed is based on
the child’s weight.
Weight must be recorded in kilograms.
Weigh child in pounds and divide number
by 2.2.
Infants should be weighed without a diaper.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
53
Temperature
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Temporal temperatures – fast, accurate
(especially in infants) and noninvasive
Tympanic temperature


Axillary temperature



Fast and accurate
Dry axilla
Leave thermometer in place until it beeps (will take
longer)
Rectal temperatures


Fragile rectal tissue that could be punctured
Feces holds heat
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54
Pulse and Respirations





Apical pulse until 3 years of age
Pulse rate may increase with inspiration and
decrease with expiration
Listen to the pulse lateral to the left nipple
Infants and young children are abdominal
breathers
Respiration rate decreases with age

Newborn: 30–60
 3 years: 20–40
 10 years: 16–22
 16 years: 15–20
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55
Blood Pressure



Use correct size of cuff
Center the bladder over the brachial artery
Increases with age


Systolic
• 1–7 years: age + 90
• 8–18 years: 2 × age + 83
Diastolic
• 1–5 years: 56
• 6–18 years: age + 52
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56
Urine Collection Devices:
Procedure 42-5
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57
Injury Prevention


The primary causes of childhood injuries
include motor vehicle accidents, drowning,
burns, falls, poisoning, aspiration with airway
obstruction, and firearm accidents.
It is the medical assistant’s responsibility to
make sure that the ambulatory care
environment is safe and parents are educated
about potential hazards.
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58
Critical Thinking Application

The office manager asked Susie if she would
check the entire office for potential child
safety issues. After inspecting the facility,
Susie is concerned about some safety issues,
so she decides to create a checklist for future
use. What precautions or safety features
should she include?
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59
Adolescent Patient




Teens have rapid growth spurts and the development of
secondary sexual characteristics.
Health examinations – height and weight; diet and
exercise routines; STD screening and Pap tests if
female adolescents are sexually active with HPV
screening; review of vaccination history with booster
administration as indicated; assessment of high-risk
behaviors such as substance abuse and sexual
behavior.
Health problems most frequently seen in adolescent
patients include eating disorders (anorexia nervosa and
bulimia nervosa), obesity, and injury-related problems.
Accidents are the leading cause of death and injury.
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60
Suicide




Third leading cause of adolescent death
Signs of depression include headaches,
abdominal discomfort, anorexia, fatigue,
aggressiveness, drug or alcohol abuse, and
sexual promiscuity
Verbal statements that hint at the adolescent’s
intention to commit suicide; talking about dying
Actions – giving away prized objects,
withdrawing from social groups, sudden
changes in normal behavior patterns, or writing
a suicide note
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61
Child Abuse


The federal Child Abuse Prevention and
Treatment Act states that all threats to a child’s
physical and/or mental welfare must be
reported.
If the medical assistant suspects that a child is
a victim of abuse, he or she should consult with
the pediatrician immediately, before the patient
is seen.
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62
Signs of Abuse
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63
Parent Education Topics
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64
Child Safety Guidelines






Position healthy full-term infants on the back or side
to sleep.
Stairs should be carpeted and protected with
nonaccordion gates.
Install and maintain smoke detectors on each floor
and near sleeping areas.
Develop and practice a plan of escape in the event of
a fire.
Put a self-latching lock on basement stairs.
Store dangerous products out of reach (including
medicines and vitamins), in cabinets with locks, and
in their original containers.
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65
Child Safety Guidelines






Keep potentially harmful plants out of reach.
Post the numbers of the Poison Control Center and
the child’s physician by all phones.
Teach children to call 911 as soon as possible.
Regularly inspect toys for sharp or removable
parts.
Use an approved car seat that is appropriate for
the child’s age every time the child is in the car,
and make certain it is properly installed.
Follow guidelines for placing children in the front
seat of motor vehicles.
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66
Child Safety Guidelines





Parents should use seat belts
Wear properly fitting, approved helmets when
biking and pads when skateboarding
If firearms are in the home, store them
unloaded, with the ammunition stored
separately, and in a locked container
If the child has access to a swimming pool,
make certain it is fenced, with self-locking gates
All adults and older children should learn
cardiopulmonary resuscitation (CPR)
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67