Caring for Children at Home

Children are not small adults. A child cannot consent to care, cannot always say what hurts and can get very sick very fast. Parents are in the room and make the decisions. This guide covers the everyday skills of working with a child at home, from talking to a three-year-old to putting a baby down to sleep. Your state, your agency and the plan of care decide which tasks are yours.

What You Will Be Able to Do

• Explain how pediatric care differs from adult care.
• Talk with children at their level.
• Observe development and report concerns.
• Follow safe sleep and car seat rules.
• Recognize a fever emergency in a young baby.
• Keep a home safer and measure liquid medicine correctly.
• Respond to suspected abuse or neglect.

How Pediatric Care Is Different

1. Parents hold the consent. A young child cannot consent to care. The legal guardian, usually a parent, makes decisions. If a parent asks for something that goes against the plan of care, call the nurse.
2. Communication is play. You get on the floor, use a stuffed animal and describe what is happening in short sentences.
3. Development shapes every task. "Help with feeding" means something different at 2 and at 7.
4. The family is the unit of care. Parents may be short on sleep and money. Your steadiness matters.
5. Siblings and pets are part of the picture. Germs and toys travel all over the house.

Talking With Children

• Get down to eye level. Sit on the floor, or kneel.
• Use short, concrete words. "I'm going to wash your feet with warm water."
• Tell them what they will see and feel. "This washcloth is warm. It goes on your belly."
• Use toys and distraction. A stuffed animal can have the first bath. Bubbles and music help too.
• Offer real choices. "Do you want to wash your hands first or your face?" Control over small things reduces fights over big things.
• Praise cooperation. "You sat so still. Great job." Do not bribe.
• Never threaten or shame. Do not say "The doctor will give you a shot if you don't behave," or "Big boys don't cry."
• Keep your face calm. Children read your face more than your words.

Watching Development

The CDC's milestone checklists list what most children, 75 percent or more, can do by each age. Children with medical conditions may be on a different schedule, so compare a child with their own care plan and past progress.

You observe and report. You do not diagnose. If a 14-month-old is not walking yet, do not tell the parent that something is wrong and do not promise everything is fine. Write down what you see and tell the nurse.

Report these promptly:

• A child who loses a skill they used to have, at any age.
• A 9-month-old who is not babbling.
• A 16-month-old with no words.
• A child who does not respond to sounds or people, or does not make eye contact.

Use plain facts: "Not sitting without support at 9 months. Rolls both ways. Babbles when mother is present. Nurse told."

Safe Sleep for Babies

Sleep-related deaths are a leading cause of death in babies under one year. The American Academy of Pediatrics (AAP) recommends the following for healthy infants. If a doctor has ordered a different plan for a medical reason, follow that plan.

• On the back, every time, for naps and at night. Side sleeping is as risky as stomach sleeping. Babies with reflux also sleep on their backs, unless a doctor orders otherwise.
• On a firm, flat surface. Use a crib, bassinet or play yard with a fitted sheet. Crib slats should be no more than 2 3/8 inches apart. A surface tilted more than 10 degrees is not safe for sleep. Move a baby who falls asleep in a car seat or swing once you arrive.
• Nothing else in the sleep area. That means no pillows, blankets, bumpers, stuffed animals or positioners.
• In a sleep sack if the baby may be cold. Use a wearable blanket, with no other bedding in the crib. Avoid weighted sleepers.
• In the parents' room, not their bed, for at least the first 6 months.
• Not too warm. Dress the baby in no more than one layer more than you are wearing. Do not use a hat indoors. Check for sweating or a hot chest.
• No smoke or vaping near the baby.

If you find a baby asleep face down in a crib with toys and blankets, or asleep on a couch or adult bed, move the baby to a safe position right away. Then gently talk with the caregiver about safe sleep, and tell the nurse.

Car Seat Basics

You may help buckle a child into a seat that a parent has installed.

• Rear-facing for as long as possible, until the child reaches the highest weight or height the seat allows. Most convertible seats allow this for 2 years or more.
• Straps. Rear-facing, the harness comes from at or below the shoulders. Forward-facing, it comes from at or above the shoulders.
• Chest clip. Put it at armpit level, over the breastbone.
• Pinch test. You should not be able to pinch any slack in the strap at the shoulder.
• No bulky coats under the harness. Coats compress in a crash. Use thin layers and put a coat or blanket over the buckled harness.
• No add-ons that did not come with the seat.

Refer questions about expired, recalled or used seats to a certified Child Passenger Safety Technician.

Fever and Sick Days

Fever means different things at different ages. Follow the care plan, and report any fever over the limit it sets.

Warning: In a baby under 3 months, a rectal temperature of 100.4°F or higher is an emergency, even if the baby seems fine. Tell the parent to call the pediatrician's emergency line or go to the emergency department right away, and notify the nurse.

Call the nurse for trouble breathing, poor feeding, vomiting or diarrhea, fewer wet diapers, unusual sleepiness or a rash. Call 911 for blue lips, severe trouble breathing, a child you cannot wake or a seizure that the plan says needs 911.

Measuring Liquid Medicine

Children's doses are small and based on weight, so a small error matters. If medicine is part of your role, follow the plan exactly.

• Use the oral syringe or dosing cup that came with the medicine, or one from the pharmacy.
• Do not use a kitchen spoon. They vary widely in size and cause dosing errors.
• Check the units. Milliliters (mL) and teaspoons are not the same.
• If the device is missing, ask the nurse or pharmacist.

Keeping the Home Safe

• Choking. For children under 4, avoid or cut up high-risk foods such as whole grapes, hot dogs, round hard candy, popcorn and nuts. Quarter grapes lengthwise, and keep small objects out of reach.
• Burns. The water heater should be set no higher than 120°F. Test bath water. Turn pot handles in.
• Poison. Keep medicines and cleaners locked up. Post Poison Control: 1-800-222-1222.
• Water. Never leave a young child alone in or near water, even in a shallow tub.
• Falls. Keep a hand on a child on a changing table, and use stair gates.
• Cars. Never leave a child alone in a car.

Infection Control

Children's germs travel fast, and a medically fragile child has little reserve.

• Clean your hands when you arrive, after diaper changes, before and after meals and procedures and after touching pets.
• Keep medical supplies apart from toys.
• Clean high-touch toys and surfaces often.
• If a sibling is sick, keep them apart from the patient when practical. A sick child over 2 can wear a mask. Reinforce hand hygiene and do not share cups.
• Leave your outerwear by the door, and bring in only what you need.
• Stay current on vaccines, and do not work sick.

Pediatric Documentation

Be concrete and use numbers when you can.

• Intake: Record the specific volumes and amounts of each item. "4 oz formula, 2 oz water, 1 jar of pears." Not "ate well."
• Output: Count wet diapers or record catheter output in mL, and note stool amount and color.
• Seizures: Record the start time, how long it lasted, what you saw before, during and after, and what you did. Do not write a medical diagnosis or a guess at the cause.
• Ventilator settings: Write down what you see. Do not touch the controls.
• Feeding tube: Record feeds if your role includes them, any vomiting and how the site looks.
• G-tube site: If the site is red or leaking, give site care as the plan says, document what you see and notify the nurse.
• Development and family: Record new words and skills, and the parent's concerns. Do not add opinions about the family.

Suspected Abuse or Neglect

Health care workers are mandated reporters in most states, and some states require every adult to report. Learn your state's rule, and treat yourself as a mandated reporter. You do not need proof. Reasonable suspicion is enough.

Watch for:

• Bruises in babies who cannot yet move around, on soft areas such as the torso, ears or neck, or in the shape of an object.
• Burns with clean edges, or round burns.
• Injuries that do not match the story, or stories that keep changing.
• Severe diaper rash, no food in the house, repeated dirtiness or medical equipment that is not cared for.
• A child telling you that someone is hurting them.

What to do:

1. If the child is in immediate danger, call 911.
2. Call your state's Child Protective Services (CPS) hotline. Telling your agency does not replace your own report if your state requires you to make it.
3. Notify your supervisor and the nurse the same day.
4. Document what you saw and heard objectively, using the child's exact words in quotes.
5. Do not question the child, and do not confront the family.

Supporting Siblings and Parents

Brothers and sisters may feel forgotten. A quick "How was school?" can mean a lot. Do not ask them to act as caregivers, and do not criticize them. Parents are often worn out, and what they need from you is reliability and kindness. If a parent mentions feeling hopeless or having thoughts of harm, tell the nurse right away. If there is immediate danger, call 911.

Common Mistakes

Check Your Understanding

1. A visiting grandmother lays a 3-month-old on his tummy on the sofa for a nap. What do you do?

Move him onto his back in his crib or bassinet right away. Then talk kindly with her about safe sleep, and tell the nurse.

2. A father says his 8-week-old feels warm. The rectal thermometer reads 101°F, and the baby is feeding well. Is this an emergency?

Yes. At this age, 100.4°F or higher is an emergency even if the baby seems well. He should call the pediatrician's emergency line or go to the emergency department now. Then notify the nurse.

3. A parent reaches for a soup spoon to give 2.5 mL of fever syrup. What do you do?

Point out that spoons are not accurate. Use the oral syringe or dosing cup that came with the medicine, and ask the nurse or pharmacist if it is missing.

4. You see a handprint-shaped bruise on a toddler's back. The mother says he fell. What do you do?

Stay calm and do not confront her. Report your reasonable suspicion to CPS, notify your supervisor and the nurse the same day and document the facts.

Key Takeaways

• Parents hold the consent, and you follow the plan of care.
• Give children real choices and speak at their level.
• Babies sleep on their backs on a firm, flat, bare surface.
• A chest clip goes at armpit level, and children ride rear-facing for as long as possible.
• A rectal temperature of 100.4°F or higher in a baby under 3 months is an emergency.
• Reasonable suspicion of abuse is enough to report.