PERIODS OF CHILDHOOD: CHARACTERISTICS AND PECULIARITIES

PERIODS OF CHILDHOOD: CHARACTERISTICS AND PECULIARITIES. PERCULIARITIES OF NEWBORN PERIOD.  

 

Growth and development of the child

Growth and development usually referred to as a unit, express the sum of the numerous changes that take place during the lifetime of an individual. The entire course is a dynamic process that encompasses several interrelated dimensions.

Growth implies a change in quantity and results when cells divide and synthesize new proteins. This increase iumber and size of cells is reflected in increased size and weight of the whole or any of its parts.

Maturation, which literally means to ripen, is described as aging or as an increase in competence and adaptability. It is usually used to describe a qualitative change, that is, a change in the complexity of a structure that makes it possible for that structure to begin functioning or to function at a higher level. Sometimes maturation designates the unfolding of traits inherent in the organism.

Differentiation is primarily a biologic description of the processes by which early cells and structures are systematically modified and altered to achieve specific and characteristic physical and chemical properties, although it is sometimes used to describe one of the trends in development, that is, mass to specific.

Development is a gradual growth and expansion. It, too, involves a change, in this case from a lower to a more advanced stage of complexity. Development is the emerging and expanding of capacities of the individual to provide progressively greater facility in functioning and is achieved through growth, maturation, and learning.

All of these processes are interrelated. Although they are simultaneous, ongoing processes, none occurs apart from the others. The child’s body becomes larger and more complex; the personality simultaneously expands in scope and complexity. Very simply, growth can be viewed as a quantitative change, and development as a qualitative change. Children “grow” by maintaining a positive balance of increase over loss in size; they “grow up” by maturing in structure and function.

 

Stages of development

Most authorities in the field of child development conveniently categorize child growth and behavior into approximate age stages or in terms that describe the features of an age-group. The age ranges of these stages are admittedly arbitrary and, since they do not take into account individual differences, cannot be applied to all children with any degree of precision. However, this categorization affords a convenient means to describe the characteristics associated with the majority of children at periods when distinctive developmental changes appear and specific developmental tasks must be accomplished. It is also significant for doctor to know that there are characteristic health problems peculiar to each major phase of development.

     Prenatal period: it lasts from conception to birth.

 

 

Prenatal period is divided into embryonic and fetal periods.

Embryonic period begins from conception to 8 weeks of gestations.

Fetal period lasts from 8 to 40 weeks of intrauterine life (by the birth).

A rapid growth rate and total dependency makes this one of the most crucial periods in the developmental process. The relationship between maternal health and certain manifestations in the newborn emphasizes the importance of adequate prenatal care to the health and well-being of the infant.

 

 

http://www.youtube.com/watch?v=3vIKwalC12U

 

 

The common diseases that appear in embryonic period (embryopathy)

·                    anencephalia,

·                    hydrocephaly,

·                    pylorostenosis,

·                    congenital malformation of lungs, kidney,

·                    congenital heart defect.

 

The common diseases that appear in fetal period (fetopathy):

·                    microsomia – decreased sizes of some parts of the body,

·   hypoplasia – organ or system of organs underdeveloped,

·   macrosomia – increased sizes of some parts of the body,

·   intrauterine infection (herpetic infection, hepatitis, rubella, mycoplasmosis, toxoplasmosis).

 

 

Infancy period: it lasts from birth to 12 months.  

Infancy is divided into neonatal and infancy.

 

Neonatal period: it begins from birth of the baby and lasts by 28 days.

 

 

 

Child immediately after birth

 

 

 

The first days of life

 

 

 

 

The common diseases that appear ieonatal period:

·   embryopathy,

·   fetopathy,

·   intrauterine infection,

·   birth ingeries (cephalhematoma, caput succedaneum, skull fracture, fractures of clavicle, humerus, facial paralysis, brachial palsy).

 

Infancy lasts from 1 to 12 months.

The infancy period is one of rapid motor, cognitive, and social development. Through mutuality with the caregiver (mother), the infant establishes a basic trust in the world and the foundation for future interpersonal relationships. The critical first month of life, although the part of the infancy period, is often differentiated from the remainder because of the major physical adjustments to extrauterine existence and the psychologic adjustment of the mother.

 

6 month of life

 

 

8 month of life

First year of life

 

The common diseases that appear in infancy:

·        rickets, rachitis,

·        anemia,

·        hypotrophy,

·        paratrophy,

·        acute diarrhea,

·        acute respiratory virus infections,

·        acute pneumonia,

·        infantile eczema.  

Early childhood includes the children in age from 1 to 6 years.

 

It is divided into toddler and preschool periods.

 

Toddler period lasts from 1 to 3 years.

 

 

 

Preschool period begins from 3 years and ended at 6 years.

 

This period, which extends from the time children attain upright locomotion until they enter school, is characterized by intense activity and discovery. It is a time of marked physical and personality development. Motor development advances steadily. Children at this age acquire language and wider social relationships, learn role standards, gain self-control and mastery, develop increasing awareness of dependence and independence, and begin to develop a self-concept.

The common diseases that appear in toddler period:

·        acute children infections (rubella, measles, scarlet fever, pertussis, chickenpox, dysentery).

The common diseases that appear in preschool period:

·        acute children infections (rubella, measles, scarlet fever, pertussis, chickenpox, dysentery),

·        tuberculosis,

·        bronchial asthma,

·        obesity,

·        rheumatism,

·        ingery.

 

Middle childhood: it lasts from 6 to 12 years.

 

Middle childhood includes prepubertal period: it begins from 10 years and completes at 12 years.

Frequently referred to as the “school age,” this period of development is one in which the child is directed away from the family group and is centered around the wider world of peer relationships. There is steady advancement in physical, mental, and social development with emphasis on developing skill competencies. Social cooperation and early moral development take on more importance with relevance for later life stages. This is a critical period in the development of a self-concept.

A developmental task is a set of skills and competencies peculiar to each developmental stage that children must accomplish or master in order to deal effectively with their environment.

 

 

 

The common diseases that appear in middle childhood:

·             chronic heart diseases (myocarditis, rheumatism),

·             chronic kidneys diseases (pyelonephritis, glomerulonephritis),

·             diseases of nervious systems,

·             scoliosis,

·             disease of eye sight.

 

 

Later childhood (adolescence period): it lasts from 12 to 18 years.

The tumultuous period of rapid maturation and change known as adolescence has been described in various ways. It is considered to be a transitional period that begins at the onset of puberty and extends to the point of entry into the adult world – usually high school graduation. Biologic and personality maturation are accompanied by physical and emotional turmoil, and there is redefining of the self-concept. In the late adolescent period the child begins to internalize all the previously learned values and to focus on an individual, rather than a group, identity.

 

 

 

 

The common diseases that appear in later childhood:

·             dysfunction of the nervous system,

·             dysfunction of the cardiovascular system,

·             dysfunction of the digestive system,

·             dysfunction of the endocrine system,

·             chronic heart diseases (myocarditis, rheumatic fever),

·             chronic kidneys diseases (pyelonephritis, glomerulonephritis),

·             diseases of the nervous system.

 

 

History taking

 

Communication skills

 

1. Communication with the patient and/or family:

·        Establish rapport with the patient and family.

·        Identify the primary concerns of the patient and/or family.

·        Recognize the triangular relationship between the physician, patient and parent and be able to communicate information to both the patient and parent, making sure both understand the diagnosis and treatment plan and have the opportunity to ask questions; be aware that the relationship changes with increasing age of the child.

·        Provide anticipatory guidance during health maintenance visits, including the newborursery visit.

·        Recognize the important role of the patient’s education in management of acute and chronic illnesses.

2. Written communication skills:

·        Write a complete summary of the history and physical examination in a timely manner which is suitable to place in the patient’s chart.

·        Outline the different formats for documenting the history and physical examination which may be used in different clinical settings.

·        Write admission orders for a hospitalized patient.

·        Write a prescription.

3. Oral communication skills:

·        Present a complete, well organized summary of the findings of the patient’s history and physical examination, modifying the presentation to fit the situation.

·        Communicate effectively with other health care workers, including consultants, nurses and social workers.

·        Explain the thought process that led to the diagnostic and therapeutic plan.

·        Use precise descriptions of physical findings and avoid vague terms and jargon, such as “clear” and “ARD”.

Interviewing

1. Patient interviews occur in a variety of clinical settings, including initial history for a hospital admission or first ambulatory visit, health maintenance visit, acute care visit, interim visit for a child with an acute or chronic health condition. The doctor should develop an awareness that in conducting a medical interview in a variety of settings, it is sometimes appropriate to obtain a complete medical history, while at other times a more limited, focused or interval history is appropriate. Initially, the emphasis should be on obtaining complete medical histories. Opportunities to do more focused work-ups should be available as the doctor builds competence.

2. Obtain a medical history from the second party (usually the parent), as well as from the patient, noting the increased reliability of obtaining information directly from the patient as the patient matures. The doctor must be aware of issues of appropriate privacy at all ages and confidentiality in older children and adolescents.

3. Obtain a relevant history that is unique to paediatrics in addition to the standard medical history.

Chief complaint

The chief complaint represents the specific reason for the child’s visit to the clinic, office, or hospital. The chief complaint may be viewed as the theme, with the present illness as the setting of this problem. Six guidelines determine appropriate recording of the chief complaint: (1) it consists of a brief statement, (2) it is restricted to one or two symptoms, (3) it refers to a concrete complaint, (4) it is recorded in the child’s or parent’s own words, (5) it avoids the use of diagnostic terms or translations, and (6) it states the duration of the symptoms.

The doctor elicits the chief complaint by asking open-ended neutral questions such as, “Tell me what seems to be the matter?”, “How may I help you?” or “What brings you here?”. Labeling-type questions such as, “How are you sick?” should be avoided, since it is possible that the reason for the visit is not because of illness. For example, the visit may be for a routine health assessment, or the chief complaint may be of a nonphysical nature.

Examples of properly recorded chief complaints for a variety of situations may be: (1) ambulatory clinic – “My child has had a runny nose and sore throat for 4 days, but today it is worse”, (2) hospital admission – “I need to have my tonsils fixed”, sore throat and repeated earaches for 5 years, and (3) health center – “We are here for a routine checkup”, last visit 1 year ago.

If the visit is for a well-child examination, one can ask, “Before we begin, is there anything of particular concern that you would like to discuss?”. This type of statement encourages the parent (or child) to bring up an issue that may not surface during routine interviewing.

Occasionally it is difficult to isolate one symptom or problem as the chief complaint because the parent may identify many. In this situation it is important to be as specific as possible when asking questions. For example, asking informants to state which one problem or symptom caused them to seek help now may help them to focus on the most immediate concern.

 

Present illness

The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Its four major components are (1) details of onset, (2) complete interval history, (3) present status, and (4) reason for seeking help now. The focus of the present illness is on all those factors that are relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present.

Analyzing a symptom. Since pain is often the most characteristic symptom denoting onset of a physical problem, it is used as a prototype for analysis of a symptom. The nurse should assess pain for (1) type, (2) location, (3) severity, (4) duration, and (5) influencing factors. The type or character of pain should be as specific as possible. However, with young children, it is almost always impossible for them to describe the pain. Asking the parents how they know the child is in pain may help to describe its type, location, and severity. For example, a mother stated, “My child must have a severe earache because she pulls at her ears, rolls her head on the floor, and screams. Nothing seems to help”.

The doctor can help older children to describe the pain by asking them if it is sharp, throbbing, dull, aching, stabbing, and so on. Whatever words they use should be recorded in quotes.

The location of the pain also must be specific. “Stomach pains” is too general description. Older children can better localize the pain if the doctor asks them to “point with one finger to where it hurts”. The doctor can also determine if the pain radiates by asking, “Does the pain stay there or move? Show me where it goes with your finger“.

The severity of pain is best determined by finding out how it affects the child’s usual behavior. Pain that prevents a child from playing, interacting with others, sleeping, and eating is most often severe. It is preferable to record pain in terms of interference with activity, rather than to quote the parent’s or child’s adjectives.

Duration of pain should include the duration, onset, and frequency of attacks. It may be necessary to describe this in terms of activity and behavior, such as “pain lasted all night because child refused to sleep and cried intermittently”.

Influencing factors are anything that causes a change in the type, location, severity, or duration of the pain. These include (1) precipitating events (those that cause or increase the pain), (2) relieving events (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down, and so on), and (5) associated events (meals, stress, coughing, and so on).

A standard method of analyzing a symptom is listed in the following outline. These three categories – onset, characteristics, and course since onset – comprise the essential data for the present illness. Although the analysis of a symptom has concentrated on discussion of physical complaints, the same process of description and investigation can be used for emotional or psychosocial problems.

 

Analysis of a symptom

             I.    Onset

a)          Date of onset,

b)         Manner of onset (gradual or sudden),

c)          Precipitating and predisposing factors related to onset (emotional disturbance, physical exertion, fatigue, bodily function, pregnancy, environment, injury, infection, toxins and allergens, therapeutic agents, and so on).

           II.     Characteristics

a)            Character (quality, quantity, consistency, or others),

b)           Location and radiation (of pain),

c)            Intensity or severity,

d)           Timing (continuous or intermittent, duration of each, temporal relationship to other events),

e)            Aggravating and relieving factors,

f)             Associated symptoms.

III. Course since onset

a)       Incidence

·          Single acute attack.

·          Recurrent acute attacks.

·          Daily occurrences.

·          Periodic occurrences.

·          Continuous chronic episode.

b)       Progress (better, worse, unchanged),

c)        Effect of therapy.

 

 

                I.      Past History:

·        Neonatal history, including birth weight; approximate gestational age; maternal complications, such as extent of prenatal care, infections, exposure to drugs, alcohol or medications; and problems in the newborn period, such as prematurity, respiratory distress, jaundice and infections.

·        Immunizations

·        Development, noting the importance of assessing developmental milestones in evaluating the health of the child.

·        Diet, noting the importance of assessing the amount, type, and method of infant feeding.

             II.      Family History: number and ages of siblings; consanguinity, known genetic disorders, early childhood deaths, cardiovascular disease, depression and alcohol abuse.

          III.      Social History: assessment of the home environment, school and peer relationships.

         IV.      Review of Systems: the relevant items are limited, but expand as the patient’s age increases.

Modify the medical history depending on the age of the child, with particular attention given to the following age groups: neonate, infant, toddler/preschool aged child, school aged child, adolescence.

 

The Physical Examination

I. Establish rapport with children of various ages in order to perform the physical examination.

II. Recognize that the age of the child influences the areas included in the exam, as well as the order of the examination, and the approach to the patient.

III. Recognize the important role of observation as a method of obtaining data in the assessment of the child.

IV. Perform complete physical examinations on an infant, child and adolescent, including the observation and documentation of normal physical findings.

V. Demonstrate the appropriate use of the limited or focused examination, particularly in the ambulatory setting.

VI. Use developmental assessment as part of the physical examination for all ages.

·        Observe how normal behaviours, such as stranger anxiety, affect the ability of the examiner to perform the examination, and develop strategies for improving rapport.

·        Perform the Denver Developmental Screening Test, and know how it is used to assess motor, language and social development.

·        Identify the physical changes of puberty and be able to conduct Tanner staging.

VII. Observe and demonstrate physical exam findings unique to the pediatric age group, and understand how findings have different clinical significance depending on the age of the child. Some examples are:

·        Appearance

1.     Recognize signs of acute illness in an infant, toddler and child by evaluating skin colour, respiration, hydration, mental status, cry and social interaction.

2.     Recognize the importance of observing the psychosocial condition of the child, including behaviour, development, body habits (height, weight, body fat), relationship to parent and examiner, and general condition.

·        Vital signs

1.     Measure heart rate, respiratory rate, blood pressure and temperature in an infant and child, demonstrating knowledge of the appropriate sized blood pressure cuff, interval to count respirations, and normal variation in temperature depending on the route of measurement (oral, rectal, axillary or tympanic).

2.     Understand that normal values of the heart rate, the respiratory rate and the blood pressure change with age.

3.     Recognize the importance of assessing vital signs in the evaluation of acute illness.

·        Measurements

1.     Accurately measure height, weight and head circumference.

2.     Plot the data on an appropriate growth chart.

3.     Understand the normal relationships between height, weight and head circumference.

4.     Recognize the usefulness of longitudinal data.

·        Head

1.     Identify the anterior and posterior fontanels and assess them.

2.     Recognize the need for careful observation of the head size and shape, symmetry, facial features, ear size and hair whorls as a part of the examination for dysmorphic features.

3.     Recognize the red reflex and strabismus.

4.     Assess hydration of the mucous membranes. 

5.     Examine the tympanic membranes using pneumatic otoscopy.

·        Neck

1.     Palpate the lymph nodes, know what anatomic areas they drain;

2.     Know that the lymph nodes are more prominent during childhood

3.     Recognize and demonstrate maneuvers that test for nuchal rigidity.

·        Chest

1.      Remember how the rate and pattern of respirations change with age, and that abdominal respirations are normal in infants.

2.     Observe the rate and effort of breathing as a measure of respiratory distress.

3.     Recognize stridor, wheezing and rales and be able to distinguish between the inspiratory and expiratory obstruction.

4.     Interpret less serious respiratory sounds such as transmitted upper airway sounds.

·        Cardiovascular

1.     Palpate pulses in the upper and lower extremities and auscultate the heart for rhythm, rate, quality of the heart sounds and murmurs.

·        Abdomen

1.     Understand that the liver edge, spleen tip and kidneys may be palpable in the normal newborn.

2.     Examine the umbilical cord for signs of infection.

3.     Examine the abdomen for distension, tenderness, rebound and mass lesions in an infant or young child with lethargy, irritability or signs of acute illness, noting the inability of the patient to communicate symptoms of abdominal complaints.

4.     Be able to do a rectal examination and recognize when it is indicated.

·        Genitalia

1.     Recognize the appearance of normal male and female genitalia in the newborn.

2.     Recognize abnormalities, including cryptorchidism, hypospadias, testicular mass in the male.

3.     Be able to examine the external genitalia of a female patient.

4.     Recognize the need for privacy at all ages.

·        Extremities

1.     Examine the hips of a newborn for dysplasia.

2.     Recognize arthritis. 

3.     Evaluate gait and limp.

·        Back

1.     Know how to test for scoliosis.

·        Neurologic examination

1.     Elicit primitive reflexes.

2.     Assess tone, gait, strength and reflexes, recognizing the importance of symmetry.

3.     Assess developmental milestones; recognize that much of the neurologic examination of infants and children is accomplished through observation alone.

·        Skin

1.     Recognize jaundice, petechiae, purpura, common birth marks (such as nevus flammeus and Mongolian spots), vesicles, urticaria and common rashes, such as erythema toxicum, impetigo, eczema, diaper dermatitis and viral exanthems.

2.     Recognize common skin findings associated with child abuse.

3.     Assess skin turgor.

 

Inspection

The method of observation is used during physical examinations. Inspection, or “looking at the patient,” is the first step in examining a patient or a body part.

 

Palpation

The method of “feeling” with the hands is used during physical examinations. The examiner touches and feels the patient’s body part with his hands to examine the size, consistency, texture, location, and tenderness of an organ or body part.

Auscultation

This method used to “listen” to the sounds of the body during a physical examination can be performed by listening with the ear but is usually done by listening through a stethoscope. Health care providers routinely auscultate a patient’s lungs, heart, and intestines to evaluate the frequency, intensity, duration, number, and quality of sounds. Health care providers also use auscultation to listen to the heart sounds of unborn infants.

Percussion

A method of “tapping” of the body parts during  physical examination with fingers, hands, or small instruments to evaluate the size, consistency, borders and presence or absence of fluid in body organs. Percussion of a body part produces a sound (like playing a drum) that indicates the type of tissue within the organ. Lungs “sound” hollow on percussion because they are filled with air. Bones and joints “sound” solid. The abdomen “sounds” like a hollow organ filled with air, fluid, or solids.

 

 

NEW BORN CHILD. PECULIARITIES OF THE NEWBORN  PERIOD. MAIN COMPONENTS OF NEUROLOGICAL AND PSYCHOLOGICAL DEVELOPMENT IN CHILDREN OF EARLY AGE. TRANSITORY STATES IN A NEWBORN PERIOD

 

Neonatal period

INTRODUCTION At the time of birth, the newborn must quickly make changes in

the respiratory system to allow gas exchange to take place in the lungs and also make changes in the circulatory system to support the change to respiratory gas exchange. These profound, vital changes are critical to maintaining extrauterine life. The first few hours after birth wherein the newborn makes these changes and stabilizes respiratory and circulatory functions is called the neonatal transition period. Other body systems also make changes in their functioning over a longer period, although

they are not crucial to the immediate survival of the infant. Nurses are instrumental in assisting the newborn and mother through the neonatal transition period.

The neonatal period extends from birth to somewhere between 2 weeks and 1 month.

Immediately after the baby is born, uterine contractions force blood, fluid, and the placenta from the mother’s body. The umbilical cord—the baby’s lifeline to it’s mother—is now severed. Without the placenta to remove waste, carbon dioxide builds up in the baby’s blood. This fact, along with the actions of medical personnel, stimulates the control center in the brain, which in turn responds by triggering inhalation. Thus the newborn takes its first breath. As the newborn’s lungs begin to function, the bypass vessels of fetal circulation begin to close. The bypass connecting the atria of the heart, known as the foramen ovale, normally closes slowly during the first year.

During this period the body goes through drastic physiological changes. The most critical need is for the body to get enough oxygen as well as an adequate supply of blood. (The respiratory and heart rate of a newborn is much faster than that of an adult.)

 

IMMEDIATE NEEDS OF THE NEWBORN

 

The immediate needs of the newborn are airway, breathing, circulation, and warmth.

Airway A clear airway is necessary for adequate gas exchange.

Breathing In utero, the fetus relied on the placenta and the mother’s respirations for gas exchange; however, fetal breathing movements, from approximately 11 weeks’ gestation, help develop the chest wall muscles and the diaphragm (Ladewig, Moberly, Olds, & London, 2005). By approximately 35 weeks’ gestation,

the surfactant produced by the alveoli is sufficient in amount (L/S ratio 2:1) to allow the alveoli to remain partially expanded when the newborn begins to breathe at birth.

For the lungs to function, two changes must happen:

• Pulmonary ventilation must be established with lung expansion at the first breath.

• Pulmonary circulation must greatly increase.

The initiation of breathing is influenced by four factors—physical, chemical, thermal, and sensory—which work together.

Physical Factors

The physical (sometimes called mechanical) factors include the compression of the fetal chest as it moves through the birth canal, which squeezes fluid from the lungs and increases intrathoracic pressure; and the chest wall recoil, which occurs as the newborn’s trunk emerges. The chest recoil creates negative intrathoracic pressure, which causes a small amount of air to replace the fluid that was squeezed out of the lungs and some of the lung fluid to move across the alveolar membranes into the interstitial tissue of the lungs. Each breath allows more air into the alveoli and more fluid into the interstitial tissue.

Because the protein concentration is higher in the capillaries, the interstitial fluid is drawn into them. All of the alveolar fluid is absorbed within the first day after birth.

Chemical Factors

When the cord is clamped, placental gas exchange ceases, causing an increase in PaCO2 and a decrease in PaO2 and pH (a transitory asphyxia). These changes stimulate the carotid and aortic chemoreceptors, which send impulses to the respiratory center in the medulla, which in turn stimulates respirations. A brief period

of asphyxia stimulates respirations, whereas prolonged asphyxia is a central nervous system (CNS) respiratory depressant.

Thermal Factors

The change in temperature from the intrauterine environment to the extrauterine environment, a decrease of more than 20°F, is also a stimulus to breathing. The colder temperature stimulates the skierve endings and the newborn breathes as

a response. Cold stress and respiratory depression result from excessive cooling of the newborn.

Sensory Factors

The comfortable, relatively quiet uterine environment is left behind for an environment full of sensory stimuli. The auditory and visual stimuli associated with birth, along with the tactile stimulation of being handled, assist in the initiation of

respirations.

Circulation

Several circulatory changes are necessary for the successful change from fetal circulation to neonatal circulation. These changes involve the pulmonary blood vessels, ductus arteriosus,foramen ovale, and ductus venosus.

Pulmonary Blood Vessels

The dilation of these blood vessels begins with the first breath taken by the newborn. This results in lower pulmonary resistance, which allows the blood to freely circulate through the lungs to be oxygenated.

Ductus Arteriosus

Within minutes after birth, the ductus arteriosus has a reversal of blood flow caused by the increased pressure in the aorta and the increase of oxygen in the blood. This results in more blood flowing through the pulmonary arteries for oxygenation.

Closure of the ductus arteriosus is complete within 24 hours and is permanent in 3 to 4 weeks.

Foramen Ovale

The foramen ovale closes within minutes after birth because of the higher pressure in the left atrium than in the right atrium. The increased blood flow in the lungs decreases pressure in the right atrium, and the return of blood from the lungs

increases the pressure in the left atrium. Closure of the foramen ovale is permanent in approximately 3 months.

Ductus Venosus

When the cord is clamped, the blood ceases flowing through the umbilical vein to the ductus venosus and into the inferior vena cava. Blood now flows through the liver and is filtered as in adult circulation.

Heat Loss

The newborn has thin skin with blood vessels close to the surface and little subcutaneous fat to prevent heat loss. Heat moves from the warm internal areas to the cooler skin surface and then to the surrounding environment. Excessive heat loss

is called cold stress. An increase in metabolism leads to a significant increase in the need for oxygen. When oxygen is used for metabolism (heat production), the infant may experience hypoxia. There may not be enough oxygen for the metabolic

rate to increase, and the newborn will not be able to maintain body temperature. Prolonged cold stress causes respiratory difficulties and a decrease in surfactant production. Less surfactant hinders lung expansion, which in turn leads to more

respiratory distress. Decreased blood oxygen may cause vasoconstriction of the pulmonary vessels with a return to fetal circulation patterns, which further increases respiratory distress.

The glucose necessary for increased metabolism is made available when glycogen stores are converted to glucose. If the glycogen is depleted, hypoglycemia results.

Brown fat metabolism results in the release of fatty acids.

Continuous brown fat metabolism, when the newborn is in a cold stress situation for a considerable time, results in metabolic acidosis, which can be life-threatening. Excess fatty acids in the blood interfere with bilirubin transportation to the liver, which

increases the risk of jaundice.

There are four methods by which the newborn loses heat: conduction, convection, evaporation, and radiation.

Conduction is the loss of heat by direct contact with a cooler object. When a newborn is touched by cold hands or a cold stethoscope or is placed on a cold surface such as a scale, heat is lost. Heat loss can be prevented by warming

objects touching the newborn. If a newborn is wrapped in a warmed blanket or placed against the mother’s warm skin, heat will be lost by the blanket or mother’s skin to the cooler newborn and the newborn is warmed.

Convection is the loss of heat by the movement of air. When air moves (air currents), heat is transferred to the air. Air currents from an open door or window, air conditioning, or from people moving around increase heat loss.

A radiant warmer is often used for the newborn immediately after birth to prevent heat loss by convection.

 

Heat loss in the newborn can be prevented by wrapping the infant in a blanket and placing a stocking cap on the head and by keeping the newborn out of any drafts.

Evaporation is the loss of heat when water is changed to a vapor. When a wet body dries, heat is lost, such as a newborn wet with amniotic fluid or during a bath.

The insensible water loss from the skin and respiratory tract also results in heat loss. Heat loss can be prevented by immediately drying the newborn at birth and after

receiving a bath, and by changing wet clothing and diapers promptly.

Radiation Radiation is the loss of heat by transfer to cooler objects nearby, but not through direct contact. An infant placed near a cold window loses heat by radiation to the sides of the crib and the window. If the walls of an incubator are cold, the infant loses heat. Heat loss can be prevented by keeping cribs and incubators away from cold windows.

 

THE NEWBORN’S APPEARANCE

A newborn’s skin is oftentimes grayish to dusky blue in color. As soon as the newborn begins to breathe, usually within a minute or two of birth, the skin’s color returns to normal tones. Newborns are wet, covered in streaks of blood, and coated with a white substance known as vernix caseosa, which is believed to act as an antibacterial barrier. The newborn may also have Mongolian spots, various other birthmarks, or peeling skin, particularly at the wrists, hands, ankles, and feet.

A newborn’s shoulders and hips are narrow, the abdomen protrudes slightly, and the arms and legs are relatively short. The average weight of a full-term newborn is approximately 7 ½ pounds (3.2kg), but can be anywhere from 5.5–10 pounds (2.7–4.6kg). The average total body length is 14–20 inches (35.6–50.8cm), although premature newborns may be much smaller. The Apgar score is a measure of a newborn’s transition from the womb during the first ten minutes of life.

A newborn’s head is very large in proportion to the rest of the body, and the cranium is enormous relative to his or her face. While the adult human skull is about 1/8 of the total body length, the newborn’s is twice that. At birth, many regions of the newborn’s skull have not yet been converted to bone. These “soft spots” are known as fontanels; the two largest are the diamond-shaped anterior fontanel, located at the top front portion of the head, and the smaller triangular-shaped posterior fontanel, which lies at the back of the head.

During labor and birth, the infant’s skull changes shape to fit through the birth canal, sometimes causing the child to be born with a misshapen or elongated head. This will usually return to normal on its own within a few days or weeks. Special exercises sometimes advised by physicians may assist the process.

Some newborns have a fine, downy body hair called lanugo. It may be particularly noticeable on the back, shoulders, forehead, ears and face of premature infants. Lanugo disappears within a few weeks. Likewise, not all infants are born with lush heads of hair. Some may be nearly bald while others may have very fine, almost invisible hair. Some babies are even born with a full head of hair. Amongst fair-skinned parents, this fine hair may be blond, even if the parents are not. The scalp may also be temporarily bruised or swollen, especially in hairless newborns, and the area around the eyes may be puffy.

A newborn’s genitals are enlarged and reddened, with male infants having an unusually large scrotum. The breasts may also be enlarged, even in male infants. This is caused by naturally-occurring maternal hormones and is a temporary condition. Females (and even males) may actually discharge milk from their nipples, and/or a bloody or milky-like substance from the vagina. In either case, this is considered normal and will disappear in time.

The umbilical cord of a newborn is bluish-white in color. After birth, the umbilical cord is normally cut, leaving a 1–2 inch stub. The umbilical stub will dry out, shrivel, darken, and spontaneously fall off within about 3 weeks. Occasionally, hospitals may apply triple dye to the umbilical stub to prevent infection, which may temporarily color the stub and surrounding skin purple.

Newborns lose many of the above physical characteristics quickly. Thus prototypical older babies look very different. While older babies are considered “cute”, newborns can be “unattractive” by the same criteria and first time parents may need to be educated in this regard.

Neonatal jaundice

Neonatal jaundice is usually harmless: this condition is often seen in infants around the second day after birth, lasting until day 8 iormal births, or to around day 14 in premature births. Serum Bilirubin initially increase because a newborn does not need as many red blood cells as it did as a fetus (since there is a higher concentration of oxygen in the air than what was available through the umbilical vein). The newborn’s liver processes the breakdown of the extra red blood cells, but some bilirubin does build up in the blood. Normally bilirubin levels drop to a low level without any intervention required. In babies where the bilirubin levels are a concern (particularly in pre-term infants), a common treatment is to use UV lights (“bili lights”) on the newborn baby.

Changes in body Size and Muscle fat makeup

By the end of the first year an infant’s height is increased by 50% and by the age of 2 the baby will have grown 75% greater.

By 5 months a baby will have doubled its weight, and tripled its weight by the first year. By the age of 2, a baby’s weight will have quadrupled.

Infants and toddlers grow in little spurts over the first 21 months of life. A baby can go through periods of 7 to 63 days with no growth but they can add as much as an inch in one 24 hour period. During the day before a growth spurt, parents describe their babies as irritable and very hungry.

The best way to estimate a child’s physical maturity is to use skeletal age, a measure of bone development. This is done by having a x-ray of the long bones of the body to see the extent to which soft, pliable cartilage has hardened into bone.

Changes in body Proportions

Cephalocaudal trend means that growth occurs from head to tail. The head develops more rapidly than the lower part of the body. At birth the head takes up to one fourth of the total body length and legs only one third. The lower body catches up by age 2 and the head accounts for only one fifth and legs for nearly one half of the body length.

Proximodistal trend means that head growth proceeds literally form near to far or from center of the body outward.

At birth the brain is nearer its adult shape and size than any other physical structure. The brain continues to develop at an astounding pace throughout infancy and toddlerhood.

The Brain Development

The neurons of infants and adults differ in 2 significant ways: Growth of neural fibers and synapses increases connective structures. When synapses are formed, many surrounding neurons die. This occurs in 20 to 80 percent of the brain region.

Dendrites synapses: Synapses are tiny gaps between neurons where fiber from different neurons come close together but do not touch. Neurons release chemicals that cross the synapses sending messages to one another. During the prenatal period the neural tube produces far more neurons than the brain will ever need. Myelinization: The coating of neural fibers with a fatty sheath called myelin that improves the efficiency of message transfer. Multi-layered lipid cholesterol and protein covering produced by neuralgia cause a rapid gain in overall size of brain due to neural fibers and myelination.

Synaptic pruning: Neurons seldom stimulated soon loose their synapses. Neurons not needed at the moment return to an uncommitted state so they can support future development. However, if synaptic pruning occurs in old age neurons will lose their synapses. If neurons are stimulated at a young age, even though neurons were pruned, they will be stimulated again.

Cerebral Cortex: Surrounding the brain, it is the largest most complex brain structure. The cortex is divided into four major lobes: occipital lobe, parietal lobe, temporal lobe, and frontal lobe which is the last to develop.

Brain plasticity: The brain is highly plastic. Many areas are not yet committed to specific functions. If a part of the brain is damaged, other parts can take over tasks that they would not normally have handled.

 

BORDERLINE (IN-BETWEEN) STATE

Till birth, the child is in the mother’s uterus, and after birth he/she gets into an environment which is completely new to him/her. Conditions considerably differ from intra-uterine: the temperature of air, various flora of the environment, extensive sound, tactile irritations etc. Simultaneously to it, in a child’s organism there are expressive internal changes: the pulmonary circulation of blood is included in action, some sites of blood-flow are closed, the child starts to breathe, the gastrointestinal tract becomes more active, etc. A newborn child has to get used to new conditions of his/her life.

Conditions of adaptation of a newborn to the external environment refer to borderline state. They appear during and after birth. There are no standard rules of their occurrence in all newborns: not every chili has all borderline state, some of them develop only in premature babes. Besides, on the basis of scientific research in the last years, it is found out, that many physiological conditions are shown only by the change in the laboratory data and have no clinical manifestations.

Normally transitory conditions disappear rather quickly. However in some cases the manifestation of physiological conditions can turn into pathological violations which becomes the reason for occurrence of diseases in the child and sometimes can leave traces for the whole life.

 

The basic borderline states are:

•  The first breath and transitory hyperventilation.

•  Physiological erythema.

•  Toxic erythema.

•  Physiological jaundice.

•  Transitory hyperthermia.

•  Physiological loss of primary weight of the body.

•  Transitory features of the kidneys.

•  Transitory polycythemia.

•  Sexual crisis.

•  Physiological dyspepsia.

 

The first breath and transitory hyperventilation: Right after birth under the influence of metabolic changes arising during delivery (hypoxia, hypercapnia, acidosis, etc.) the activation of the respiratory center occurs, and the child does the first breath.

During the first 2-3 days in every newborn the borderline state—transitory hyperventilation is observed, its structure includes the following processes:

·        High frequency of breath (up to 60 per minute).

·        Periodic breath of’ gasping’ type — a deep inspiration and troublesome expiration — is marked in 4-8% of all respiratory movements during the first 3 hours of life; further on the frequency of breathing of ‘gasping’ type decreases.

·        The lungs are filled with air and released from liquid.

·        The shunts between lesser and greater circulations, which the fetus had before, are closed (see “Cardiovascular system”), arteries extend and vascular resistance in the lungs is reduced, and as a result the pulmonary blood-flow increases.

 

Transitory hyperventilation provides intensive expansion of the lung tissue with more and more active participation of the lungs in the act of breathing and, as a result of this, large amount of air enters during inspiration. This borderline state will be manifested by the fact, that in 30 minutes after delivery (it is an acute phase of adaptation to extrauterine life) during the first 2-3 days the pulmonary ventilation during a minute in the child is 1.5-2 times more than during the next days. The existed hypercapnia in blood of the child during delivery is replaced into necessary hypocapnia.

 

Physiological erythema

For toxic erythema, arising on the 2^nd-5^th day of the life in 20-30% of newborns, the following manifestations are characteristic:

•  Localization of erythema — around joints of extremities, on the extensor surface of thigh, buttocks, chest, abdomen, face of the child. It nevtl happens on the palms, feet and mucous membranes.

•  Characteristic signs — red spots a little thick at palpation, in the center of which papules of grey-yellow color or blisters can be seen.

•  The quantity of spots — can be single, or all over the body.

•  Duration — Sometimes after the first spots the new ones arise, but In 2-3 days they all disappear.

 

The physiological jaundice

Transitory hyperthermia — on the 3^rd-5^th day of life the temperature of it newborn child sometimes rises up to 38.5-39.5°C.

Etiology:

·          Overheating (the temperature of the air in a chamber is higher than 24°l the arrangement of the bed near a heating radiator, under direct solar rays).

·          If the newborn dosen’t get the necessary amount of liquid.

 

The physiological loss of body weight

At birth, for a full-term newborn, the body weight at an average is 3.500 g for the male child and 3.350 g for the girl child. Permissible normal fluctuations of body weight are from 2.700 g till 4.000g. If the body weight at birth exceeds 4000 g. then the child is considered large.

In the first days after the birth the child’s weight decreases a little. This is called physiological loss of body weight. A reduction of weight up to 6-8% from weight of the body at birth is considered as a maximum limit. This process continues for up to the third day of life and by the 7′^h-8′^h day the weight of the newborn is restored — such ideal type of changes are noticed in 1/5 of all newborn. In the rest cases the necessary increase in body weight till the initial value is delayed till the second week of a life — the slow type- In rare cases the restoration of body weight occurs in the third week of the life of the child.

Physiological loss of body weight is due to the following factors: in the first day of life, the child receives a small amount of mother’s milk at the loss of a great amount of energy because right after the birth all organs and systems of the newborn starts functioning. Three quarters of the lost body weight are due to the “perspiratio insensibilis” that is due to excretion of liquids without the sensation of this process through skin. The liquid is lost through the functional respiratory system after birth also. Excretion of urine, meconium, falling off of the umbilical cord and drying of umbilical wound are the other reasons of reduction of body weight of a newborn.

The length of the body of a newborn is of special importance as a parameter of maturity of the organism. Normally to is equal to 50 cm (50.7 cm and 50.2 cm for boys and girls respectively). Permissible fluctuations are 46-56 cm.

The head circumference of the child at birth is 34-36 cm (agreeable size — 32-38 cm: according to Carol Copper’s The Baby & Child Question & Answer Book’ M., 2006. — 240 pgs, [pg. 61) — 31-39 cm) and the chest circumference is 32-34 cm

 

Transitory features of the function of kidneys

The basic kinds of borderline states of kidneys are: anuria, oliguria, albuminuria and uric acid infarct.

The signs of anuria — the absence of urinations — within 12 hours after the birth is shown in most children (and 10% of newborns for the first time urinate only in 24 hours).

Oliguria — the reduction in the amount of urine — takes place iil newborns in the first 3 days of life.

For calculating the necessary daily volume of urine which is excreted by rate mature infant during the first week, such formula is used:6-8 ml x day of life x body weight (kg)

Albuminuria is the excretion by every newborn a considerable amount of protein in urine during the first days of life. Albuminuria is caused by the Increased permeability of the epithelium of glomeruli and canals of the kidneys.

The basis of uric acid infarct is the increased destruction of the cells basically of leukocytes, caused by the catabolic character of metabolism

in  newborn. During the final stage of disintegration of the nucleus of cells, uric acid is formed. Newborns have 5-10 mg/kg of nitrogen of uric acid in the daily amount of urine that is 2-3 times more, than in adults.

Uric acid infarct is shown by deposition of uric acid in the form of crystals in the lumen of collective tubules and in ductus pappilaris of kidneys. The crystals look like thin strips of yellow-orange color in the form of rays from renal pelvis. II does not render any pathological influence on the epithelium of canals.

Uric acid infarct is developed in 1/3 of children by the end of the first week of life.

Approximately 50% of children during their first week have infarct-urine — turbid, of yellow-brick color. At microscopic research, leukocytes, epithelium, hyaline and granular cylinders can be found in increased quantity in urine. Normally, by the end of the first week these changes disappear.

Transitory polycythemia (erythrocytosis) is the increase in quantity of hemoglobin (Hb) in blood above 220 g/L (normally — 180-220 g/L) or hematocrit (Ht) — higher than 0.65 (normally — 0.55-0.65). Such polycythemia develops in 2-5% of the term newborns and up to 15% of preterm born children.

 

The sexual crisis (hormonal crisis) takes place in 70% of newborns. The most widespread signs of the sexual crisis, mostly observed in girls, are:

Desguamative vulvovaginitis (arises on the 1^st-3^rd day of life in 2/3 of newborn girls) is a significant gray-white color secretion from the vagina which gradually disappears in 2-3 days.

 

Physiological mastopathy (the induration of mammary glands): Mastopathy is caused by sexual hormones of the mother’s placenta which are included into intra-uterine blood circulation at the end of pregnancy. This signs arises on the 3^rd-4^h day of life: its maximal increase is marked on the 5^h-10^th day. Then mammary glands gradually decrease and reach the normal sizes by the end of the neonatal period. The characteristic signs of physiological mastopathy are:

•  Skin usually has natural color or with little hyperemia.

•  The process is symmetric.

•  Increase in diameter is not more than 1.5-2 cm.

•  Often on squeezing the glands, excretion of contents which are at first greyish, and then — milk color), it is similar In structure to colostrum secreted from mother’s mammary glands during last days of pregnancy.

 

Metrorrhagia is the secretion from the vagina of approximately 1 ml of blood during 1-3 days on the 5^th-8′^h day of life in 5-10% of girls.

 

Milia. Sweat glands are underdeveloped at birth. Sometimes miliaria are seen on the skin of a child they are occluded excretory channels of sweat glands which look like drops of water. Their formation comes to an end on the forehead and head first, later — on the skin of thorax and back. The most active sweating presents within the first two months of life. An adequate sweating response to the environment temperature is marked only in children of 7 years of age.

 

Physiological dyspepsia is stool disorder in a newborn on the 3^rd-4′^h day of life.

Meconium is passed during the 1^st, 2^nd, sometimes the 3^rd day of life. On the 3^rd-4^lh day meconium is replaced by transitional stool. The frequency of excretions at this time is increased, and the stool is characterized by the following signs of physiological dyspepsia:

 

•  Consistence — the stool is liquid, watery (there is a stain around feces) with lumps and mucous.

•  Color — different sites of stool have different color (white, yellow, bright and dark green).

These two signs specify non-homogeneity (i.e. heterogeneity) of stool,

•         The microscopic structure — in stool there are plenty of leukocytes (25-30 in r/v), fatty acids and mucous.

The transitional stool is passed during 2-4 days, then it becomes homogeneous in consistence (porridge-like) and yellow in color. The amount of leukocytes in it decreases to 20-10 in r/v, there are no fatty acids.

 

REFLEXES OF THE NEWBORN

            There are three groups of reflexes in the newborn. The first group includes the unconditioned reflexes that persist throughout life. They are divided into swallowing reflex, papillary reflex, sneeze reflex, blinking or corneal reflex, glabellar reflex, yawn reflex, cough reflex, gag reflex, and tendon reflexes.

The second group includes the ttransitional reflexes or reflexes of neonate and infancy. These reflexes disappear during infancy. The transitional reflexes are divided into:

1.                 The reflexes of oral automatism.

2.                 Spinal automatism.

3. Myelocephalic reflex.

            The third group includes the righting reflexes that reflexes are absent in the newborn and appear during infancy. The examples of the righting reflexes are upper Landau’s reflex, low Landau’s reflex and a parachute reflex.

Upper Landau’s reflex appears at 4 month. When an infant is placed on the abdomen, he can lift the head and the front portion of the chest about 90 degrees above the table, bearing his weight on the forearms.

Low Landau’s reflex appears at 5-6 month. When an infant prones he extends and holds (lifts) his legs.

Parachute reflex elicits a protective response to falling, and appears at 7 months.

 

Assessment of the reflexes in the normal neonate

 

Gross motor behavior

Gross motor behavior includes developmental maturation in posture, head balance,

 sitting,

 

 creeping,

 

 standing,

and walking.

 

The full-term neonate is born with some ability to hold the head erect and reflexly assumes the postural tonic neck position when supine. Several of the primitive reflexes have significance in terms of development of later gross motor skills. The righting reflexes are those reflexes that elicit certain postural responses, particularly of flexion or extension. They are responsible for certain motor activities, such as rolling over, assuming a crawl position, and maintaining normal head-trunk-limb alignment during all activities. The neck-righting reflex, which turns the body to the same side as the head, enables the child to roll over from supine to prone. Other reflexes, such as the otolith-righting and labyrinth-righting reflexes, enable the infant to raise the head.

The asymmetric tonic neck reflex, which persists from birth to 3 months, prevents the infant from rolling over. The symmetric tonic neck reflex, which is evoked by flexing or extending the neck, helps the infant to assume the crawl position. When the head and neck are extended, the extensor tone of the upper extremities and the flexor tone of the lower extremities increase. The child extends the arms and bends the knees. Because of the strong flexor tone of the lower extremities, the infant may initially crawl backward before forward. This reflex disappears wheeurologic maturity allows actual crawling to occur because independent limb movement is required.

 

 

Initial assessment of new born

The newborn requires thorough, skilled observation ensure a satisfactory adjustment to extra uterine life. Physical assessment following delivery can be divided into four phases

In additional nurse must be aware of those behaviors that signal successful attachment between the infant and parents.

The most frequently using methods to assess the newborn’s immediate adjustment to extra uterine life are the Apgar score system. The score is base on the observation of heart rate, respiratory effort, muscle tone, reflex irritability, and color. 

 

APGAR SCORING

 

 

Each item is given a score of 0, 1, or 2.Evaluation of all the categories are made 1 and 5 minutes after birth and are repeated until the infant’s condition stabilizes. Total scores of 0 to 3 represent sever distress , scores of 4 to 6 signify moderate difficulty, and score 7 to 19 indicate the absence of difficulty in adjusting to extra uterine life. Many newborn don’t achieve a score of 10 because the body is not completely pink. The  score is affected by the degree of

physiologic immaturity, infection, congenital malformation, maternal sedation or analgesia and neurological disorderthe apgar score reflect the general condition of the infant at 1 and 5 minutes based  on the five parameters given above.

 

Transitional Assessment: Periods of Reactivity

The newborn exhibits behavioral and physiologic characteristic that can at first appear to be signs of stress. However, during the initial 24 hours changes in heart, respiration, motor activity, color, mucus production, and bowel activity occur in an orderly, predictable sequence, which is normal and indicate lack of stress, distress infants also progress through these stages but at a slower Rate.

The first period of reactivity is from 6 to 8 hours after birth the newborn in. during the first 30 minutes the infant is very active, cries vigorously, may suck a fist greedily, and appears very interested in the environment. At this time the neonate’s eyes are usually open suggesting that this is an excellent opportunity for mother, father and the child to see each other. The newborn has a vigorous suck reflex; this is an opportunity time for the mother to begin breast feeding.

The new born usually grasp the nipple quickly, satisfying both mother and child. After this highly active state the infant be quite sleepy and uninterested in sucking. Physiologically the respiratory rate be high as 80 breath /min, crackle may heard, heart rate  may reach 180beats/min, bowel sound are active, mucus secretion  are increase, and temperature may decrease slightly.The second stage of first period of reactivity, after the initial stage of alertness and activity, the infant enters the second stage of period of reactivity. This period is last for 2 to 4 hours. Heart rate and respiratory rates decrease, temperature continues to fall, mucus production decrease and urine or stool is usually not passed. The infant is in a state of sleep and relative calm. Any attempt at stimulation usually elicits a minimal response .because of the decrease in the body temperature. Avoid undressing or bathing the infant during this time.

The second period of the reactivity: begins when the infant awakes from this deep sleep; its last about 2 to 5 hours and provides another excellent opportunity for child and parents to interact .the infant is again alert and responsive, heart and respiratory rates increase, the gag reflex is active, gastric and respiratory secretion are increased, and passage of meconium commonly occur. This period is usually over when the amount of the respiratory mucus has decreased. Following this period is the period of stabilization of physiologic system and a vacillating pattern of sleep and activity.

 

Pattern of sleep and activity:

The infant’s sleep and wakefulness comprise five distinct states; state refers to an interaction between the infant and the environment in which the infant’s behavior form a continuum from arousal to consciousness. The cycle of these states highly variable and is based on the number of hours an infant sleeps per day, which may range anywhere from 16 to 18 hours (Ferber) and Kryger, 1995).Approximately 50% of total sleep time is spent in irregular or rapid eye movement (REM) sleep. Sleep period last 20 min to 6 hours with little day night differentiation, which begins to develop during the first month of life. Period of sleep and period of activity are highly influence by environment stimuli.

 

 

Cry: The new born should begin extra terrine life a strong cry. The duration of crying is as highly variable in each infant as is the duration of sleep pattern. Some newborn may cry for as little as 5 min or as much as 2 hours or more per day.

Absent, weak, or constant sever respiratory disturbance. Absent, weak, or constant crying may suggest brain damage.

A high pitched shrill cry may be a sign on increase intracranial pressure.

Assessment of attachment behaviors;

One of the most important areas of assessment is careful observation of those behavior that are thought to indicate the formation of emotional bonds between the new born and family, especially the mother. Bonding representing the development of emotional ties from parent to infant and attachment represent the emotional ties from infant to parent, term are used interchangeably to denote both processes. Assessment of attachment requires much skilled observation

and interview.

 

Clinical Assessment of Gestational Age:

 Assessment of gestational age is an important criterion because perinatal morbidity and mortality are related to gestational age and birth weight. A frequent used method of determining gestational age is the simplified assessment of gestational age by the Ballard scale. An abbreviation version of the Dudowitz scale can be used to measure gestational ages of infant between 35 and 42 weeks.It assesses sis external physical and six neuromuscular signs. Each sign has a number score, and the cumulative score

correlates with a maturity rating of 26 to 44 week of gestation. The new Ballard scale a revision of the original scale, can be used with newborn as young as 20 weeks of gestation. The tool has the same physical and neuromuscular

section includes -1 and -2 scores that reflect signs of extremely premature infant, such as fused eye lids, imperceptible

breast tissue, sticky ,friable, transparent skin, no lanugo;and squares window(flexion of wrist)angle greater than 90 degree. The examination of infant with a gestational age of 26 weeks or less should be performed a postnatal age less than 12 hours. For infants with a gestational age of at least 26 week, the examination can be performed up to 96 hours after birth. To ensure accuracy, it is recommended that the initial examination be performed within the first 48 hours of life. neuromuscular adjustment following birth in extremely immature neonates require that follow up examination be performed to further validate neuromuscular criteria.The scale over estimation age by 2 to 4 days in infants younger than 37 weeks of gestation , especially at gestational ages of 32 to 37 week

Weight related to gestational Age; The weight of the infant at birth also correlates with the incidence of  perinatal morbidity and mortality. Birth weight alone, however is a poor indicator of gestational age and fetal maturity. Maturity implies functional capacity- the degree o which the neonate’s organ systems are able to adapt to the requirement of extra uterine life. Therefore gestational age is more closely related to fetal maturity than is birth weight. Because heriditary influence size at birth, it is important to note the size of other family members at birth, it is important to note the size of other family member as part of the assessment process.

The infant birth weight, length ,and head circumference are plotted on standardized graphs that identify normal values for gestational age the infant whose weight is appropriate for gestational age (AGA)(between the 10th and

90thpercentiles)can be presumed to have grown at normal rate regardless of the length of gestational –preterm,term,or post term.

Large for gestational age (LGA) (above 90th percentile) can be presumed to have grown at an accelerated rate during fetal life.

 

Small-for –gestational age (SGA) infant (below 10th percentile) can be presumed to have grown at a retarded rate during intrauterine life.

When gestational age is determine according to the Ballard scale , the new born will fall into one of the following nine

possible categoriesfor birth weight and gestational age;

AGA-term , preterm, post term

SGA–term, preterm, post term

LGA-term, preterm postterm.

 

PHYSICAL ASSESSMENT:

Vital sign-

Temperature range from 36-37C

Crying may increase body temperature

Slightly radiant warmer will falsely increase the temperature,

Heart rate

Apical 120 -140 beats/min

Common variation

Crying will increase heart rate, sleeping will decrease heart rate,

During the period of reactivity (6 to 8hrs) heart rate can reach 180 beats/min

Respiration

 30-60 breath

Common variation

     Crying will increase, sleep will decrease respiratory rate

     Blood pressure

     During the first period of reactivity (6 to8 hours), rate can reach 80 breaths/min

Blood pressure

Oscillometric -65/41mmhg in arm and calf

Common variation

Crying will increase b.p

Thigh BP may be higher than arm or calf BP by 4-8mmhg

(Oscillometric systolic pressure in calf 6-9mmhg in upper extremities then it is a sign of coarctation of aorta)

      General measurement:

Head circumference-33-33.5(13-14inch), about 2-3cm (1inch larger than chest cm):

Chest circumference- 30.5-33cm (12-13inch)

Crown to rump length- 31-35(12.5-14inch) approximately equal to head circumference.

Head to heel- 48-53cm (19-21inch)

   

General appearance:

Posture –flexion of head and extremities, which rest on chest and abdomen.

Common variation

Frank breech –extended legs, abducted and fully rotated thigh, fatten occiput, extended neck.

Skin:

1.      Skin reddish in color, smooth and puffy at birth

2.      At 24 – 36 hours of age, skin flaky, dry and pink in color

3.      Edema around eyes, feet, and genitals

4.      Vernix caseosa

5.      Laungo

6.      Turgor good with quick recoil

7.      Hair silky and soft with individual strands

8.       Nipples present and in expected locations

9.       Cord with one vein and two arteries

10.    Cord clamp tight and cord drying

11.    Nails to end of fingers and often extend slightly beyond

 

 

Head: Anterior fontanel diamond shaped 2-3 – 3-4 cms

Posterior fontanel triangular 0.5 – 1 cm

Fontanels soft, firm and flat

Sutures palpable with small separation between each

 

 

Eyes

• Slate gray or blue eye color
• Fixation at times – with ability to follow objects to midline
• Red reflex
• Distinct eyebrows, Cornea bright and shiny,Pupils equal and reactive to light

 

 

Ears

Pinna top on horizontal line with outer canthus of eye.Loud noise elicits Startle Reflex. Flexible pinna with cartilage present

 

 

Nose:Nostrils patent bilaterallyNo nasal discharge

 

 

Mouth and Throat: Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.Palate

high arched. Uvula midline. Minimal or absent salivation. Tongue moves freely and does not protrude. Well developed

fat pads bilateral cheeks. Presence ofSucking reflex,Rooting reflex,Gag reflex,Extrusion reflex

 

 

Neck

Short and thick,Turns easily side to side,Clavicles intact,Tonic neck reflex present,Neck-righting reflex present.Some head control present.

Signs of potential distress or deviations from expected findings

Torticollis-stiff neck drawing head to one side and chin pointing to opposite side Resistance to flexion

Webbing of neckLarge fat pad on back of neck

Palpable crepitus, movement with palpation of clavicle

 

Chest: Evident xiphoid process

Equal anteroposterior and lateral diameter

bilateral synchronous chest movement

Symmetrical nipples

 

 

 

Lungs

Respiration chiefly abdomen Cough reflex absent, present by 1-2 days bilateral equal bronchial breath sound

 

 

Heart: Apex –fourth to fifth intercostals space, lateral to left sternal borders.S2 slightly shaper and higher than S1.

 

 

Abdomen

Dome-shaped abdomen

Abdominal respirations

Soft to palpation

Well formed umbilical cord

Three vessels in cord

Cord dry at base

Liver papable 2 – 3 cms below right costal margin

Bilaterally equal femoral pulses

Bowel sounds auscultated within two hours of birth

Voiding within 24 hours of birth

Meconium within 24 – 48 hours of birth

 

Common variations

Small umbilical hernia

Signs of potential distress or deviations from expected findings

Bowel sounds absent

Peristaltic waves visible

Abdominal distention

Palpable masses

Scaphoid-shaped abdomen

Omphalocele

Base of cord with redness or drainage

Cord with two vessels

 

Female Genitalia

Edematous labia and clitoris

Labia majora are larger and surrounding labia minora

Vernix between labia

 

Common variations  Hymenal tag, Pseudomenstruation.Increased pigmentation. Ecchymosis and edema after breech birth. “Red brick” pink-stained urine due to uric acid crystals

Signs of potential distress or deviations from expected findings Labia fused Fecal discharge from vaginal opening Imperforate hymen Ambiguous genitalia Widely separated labia

 

Male Genitalia

Urinary meatus at tip of glans penis

Palpable testes in scrotum

Large, edematous, pendulous scrotum, with rugae

Stream adequate on voiding

 

Common variations Prepuce covering urinary meatus Erections Increased pigmentation Edema and ecchymosis after breech delivery

Signs of potential distress or deviations from expected findings Non palpable testes Hypospadius Epispadius Scrotum smooth Ambiguous genitalia

 

Back and Rectum

Intact spine without masses or openings

Trunk incurvature reflex

Patent anal opening

“Wink reflex” present

Signs of potential distress or deviations from expected findings

Limitation of movement

Fusion of vertebrae

Spina bifida

Tuft of hair

Imperforate anus

Anal fissures

Pilonidal cyst

 

Extremities

Maintains posture of flexion

Equal and bilateral movement and tone

Full range of motion all joints

Ten fingers and ten toes

Legs appear bowed

Feet appear flat

Palmar creases present

Sole creases present

Negative hip click

Grasp reflex present        

 

Signs of potential distress or deviations from expected findings

Unequal tone

Asymmetrical movement of extremities

Polydactyly

Syndactyly

Unequal leg length

Asymmetrical skin creases posterior thigh

Dislocation of hip

Persistent cyanosis of nail beds

Marked metatarus varus

 

Neuromuscular System:

Maintains position of flexion

when prone, turns head side to side

Holds head and back in horizontal plane when held prone

Ability to hold head momentarily erect

 

Signs of potential distress or deviations from expected findings

Hypotonia

Quivering

Limp extremities or straightening of extremities

Clonic jerking

Paralysis

 

INFANCY AND EARLY CHILDHOOD.

Nutrition, physical activity, sleep, safety, and emotional, social, and physical growth along with parental well-being are critical for all children. For each well child visit, there are topics that are specific to individual children based on their age, family situation, chronic health condition, or a parental concern, for example, “back to sleep,” activities to lose weight, and fences around swimming pools. Attention should also be focused on the family milieu, for example, screening for maternal depression (especially postpartum depression) and other mental illness, family violence, substance abuse, nutritional inadequacy, or lack of housing. These issues are essential to the care of young children.

Answering parents’ questions is one of the most important priorities of the well child visit. Promoting family-centered care and partnership with parents increases the ability to elicit parent concerns, especially about their child’s development, learning, and behavior. It is important to identify children with developmental disorders as early as possible. Developmental surveillance at every visit combined with a structured developmental screening at some visits is a way to improve diagnosis, especially of some of the more subtle language delays.

MIDDLE CHILDHOOD AND ADOLESCENCE.

As the child enters school-aged years, additional considerations emerge. The six health behaviors that are most important in adolescent and adult morbidity and mortality are: nutrition, physical activity, sexuality related behavior, tobacco, alcohol and other drug use, behaviors that contribute to unintentional and intentional injuries, and violence. Emotional well-being with attention to the developmental tasks of adolescence (competence at school and other activities, connection to friends and family, autonomy, empathy, and a sense of self-worth), as well as early diagnosis and treatment of mental health problems, are of equal importance.

OFFICE INTERVENTION FOR BEHAVIORAL AND MENTAL HEALTH ISSUES.

Twenty percent of primary care encounters with children are for a behavioral or mental health problem, or are sickness visits complicated by a mental health issue. Pediatricians need increased knowledge for diagnosis, treatment, and referral criteria for attention-deficit/hyperactivity disorder (ADHD), depression, anxiety, and conduct disorder, as well as an understanding of the pharmacology of the frequently prescribed psychotropic medications. Encouragement of behavioral change is also an important responsibility of the clinician. Motivational interviewing provides a structured approach that has been designed to help patients and parents identify the discrepancy between their desire for health and their behavioral choices. It also allows the clinician to use proven strategies that lead to a patient-initiated plan for change.

STRENGTH-BASED APPROACHES AND FRAMEWORK.

Questions about school or extracurricular accomplishments or competent personal characteristics should be integrated into the content of the well child visit. This often sets a positive context for the visit, deepens the partnership with the family, and acknowledges the child’s healthy development. This facilitates discussing social-emotional development with children and their parents. There is a strong relationship between appropriate social-emotional development (e.g., children’s strong connection to their family, social friends, and mentors; competence, empathy, and appropriate autonomy) and decreased participation in all the risk behaviors of adolescence (related to drugs, sex, and violence). An organized approach to the identification and encouragement of a child’s strengths during health supervision visits provides both the child and parent with an understanding of how to promote healthy achievement of the developmental tasks of childhood and adolescence. Children with special health needs often have a different timetable, but they have an equal need to be encouraged to develop strong family and peer connections, competence in a variety of arenas, ways to do things for others, and appropriate independent decision-making.

OFFICE SYSTEM CHANGE FOR QUALITY IMPROVEMENT.

Some of the office strategies to improve the preventive services delivered to children and youth include screening schedules and parent handouts, flow sheets, registries, and the use of parent and youth previsit questionnaires. These efforts are part of a larger national effort that is built on a coordinated team approach in the office setting and the use of continuous measurement for improvement.

EVIDENCE.

The clinical encounter with the well child is guideline and recommendation driven and requires the integration of clinician goals, family needs, and community realities in seeking better health for the child. Few well child care activities have been evaluated for efficacy, yet these activities are highly valued; lack of evidence is not the same as lack of benefit. The rationale for well child care activities is a balance of evidence from research, clinical practice guidelines, professional recommendations, expert opinion, experience, habit, intuition, and preferences or values. Clinical or counseling decisions and recommendations may also be based on legislation (seatbelts), on common sense measures not likely to be studied experimentally (lowering water heater temperatures), or on the basis of relational evidence (television watching associated with violent behavior in young children). Most important, sound clinical and counseling decisions are responsive to family needs and desires, and support “patient-centered decision-making.”

CARING FOR THE CHILD AND YOUTH IN THE CONTEXT OF THE FAMILY AND COMMUNITY.

A successful primary care practice for children incorporates families, is family centered, and embraces the concept of the medical home. A medical home is defined by the AAP as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. In a medical home, a pediatrician works in partnership with the family and patient to assure that all medical and nonmedical needs of the child are met. Through this partnership, the child health care professional helps the family/patient access and coordinate specialty care, educational services, out-of-home care, family support, and other public and private community services that are important to the overall health of the child and family.

Ideally, health promotion activities occur not only in the medical home, but also in partnership with community members and other health and education professionals. This rests on a clear understanding of the important role that the community plays in supporting healthy behaviors among families. Communities where children and families feel safe and valued, and have access to positive activities and relationships, provide the important base that the health care professional can build on and refer to for needed services that support health but are outside the realm of the health care system or primary care pediatric office. It is important for the medical home and community agencies to identify mutual resources, communicate well with families and each other, and partner in designing service delivery systems. This interaction is the practice of community pediatrics, whose unique feature is its concern for all of the population: those who remain well but need preventive services, those who have symptoms but do not receive effective care, and those who do seek medical care either in a physician’s office or in a hospital.

 

The newborn (neonatal) period begins at birth and includes the 1st mo of life. During this time, marked physiologic transitions occur in all organ systems and the infant learns to respond to many forms of external stimuli. Infants thrive physically and psychologically only in the context of their social relationships. Therefore, any description of the newborn’s developmental status has to include consideration of the parents’ role as well.

PARENTAL ROLE IN MATERNAL-INFANT ATTACHMENT

Parenting a newborn infant requires dedication because a newborn’s needs are urgent, continuous, and often unclear. Parents must attend to an infant’s signals and respond empathically. Many factors influence parents’ ability to assume this role.

PRENATAL FACTORS.

Pregnancy is a period of psychologic preparation for the profound demands of parenting. Women may experience ambivalence, particularly (but not exclusively) if the pregnancy was unplanned. If financial worries, physical illness, prior miscarriages or stillbirths, or other crises interfere with psychologic preparation, the neonate may not be welcomed. For adolescent mothers, the demand that they relinquish their own developmental agenda, such as an active social life, may be especially burdensome.

The early experience of being mothered may establish unconsciously held expectations about nurturing relationships that permit mothers to “tune in” to their infants. These expectations are linked with the quality of later infant-parent interactions. Mothers whose early childhoods were marked by traumatic separations, abuse, or neglect may find it especially difficult to provide consistent, responsive care. Instead, they may reenact their childhood experiences with their own infants as if unable to conceive of the mother-child relationship in any other way. Bonding may be adversely affected by several risk factors during pregnancy and in the postpartum period, which undermine the mother-child relationship and may threaten the infant’s cognitive and emotional development ( Table 7-1 ).

TABLE 7-1   — Prenatal Risk Factors for Attachment

Recent death of a loved one      Previous loss of or serious illness in another child      Prior removal of a child      History of depression or serious mental illness      History of infertility or pregnancy loss      Troubled relationship with parents      Financial stress or job loss      Marital discord or poor relationship with the other parent      Recent move or no community ties      No friends or social network      Unwanted pregnancy      No good parenting model      Experience of poor parenting      Drug and/or alcohol abuse      Extreme immaturity

From Dixon SD, Stein MT: Encounters with Children: Pediatric Behavior and Development, 3rd ed. St. Louis, Mosby, 2000, p 74.

 

 

Social support during pregnancy, particularly support from the father and close family members, is also important. Conversely, conflict with or abandonment by the father during pregnancy may diminish the mother’s ability to become absorbed with her infant. Anticipation of an early return to work may make some women reluctant to fall in love with their babies due to anticipated separation. Returning to work should be delayed at least until after 6 wk, when feeding and basic behavioral adjustments have been established.

Many decisions have to be made by parents in anticipation of the birth of their child. The most important choice is that of how the infant will be nourished. Among the important benefits of breast-feeding is the role of promoting bonding. Providing breast-feeding education for the parents at the prenatal visit by the pediatrician and by the obstetrician during prenatal care can increase maternal confidence in breast-feeding after delivery and reduce stress during the newborn period (see Chapter 42 ).

PERIPARTUM AND POSTPARTUM INFLUENCES.

The continuous presence during labor of a woman trained to offer friendly support and encouragement (a doula) results in shorter labor, fewer obstetric complications (including cesarean section), and reduced postpartum hospital stays. Early skin-to-skin contact between mothers and infants immediately after birth may correlate with an increased rate and longer duration of breast-feeding. Most new parents value even a brief period of uninterrupted time in which to get to know their new infant, and increased mother-infant contact over the first days of life may improve long-term mother-child interactions. Nonetheless, early separation, although predictably very stressful, does not inevitably impair a mother’s ability to bond with her infant. Early discharge home from the maternity ward may undermine bonding, particularly when a new mother is required to resume full responsibility for a busy household.

THE INFANT’S ROLE IN MATERNAL-INFANT ATTACHMENT

The in utero environment contributes greatly but not completely to the future growth and development of the fetus. Abnormalities in maternal-fetal placental circulation and maternal glucose metabolism or the presence of maternal infection can result in abnormal fetal growth. Infants may be small or large for gestational age as a result. These abnormal growth patterns not only predispose infants to an increased requirement for medical intervention but also may affect their ability to respond behaviorally to their parents.

PHYSICAL EXAMINATION.

Examination of the newborn should include an evaluation of growth and an observation of behavior. The average term newborn weighs approximately 3.4 kg (7½ lb); boys are slightly heavier than girls are. The average length and head circumference are about 50 cm (20 in) and 35 cm (14 in), respectively, in term infants. Each newborn’s growth parameters should be plotted on growth curves specific for that infant’s gestational age to determine the appropriateness of size. The infant’s response to being examined may be useful in assessing its vigor, alertness, and tone. Observing how the parents handle their infant, their comfort and affection, is also important. The order of the physical examination should be from the least to the most intrusive maneuver. Assessing visual tracking and response to sound and noting changes of tone with level of activity and alertness are very helpful. Performing this examination and sharing impression with parents is an important opportunity to facilitate bonding (see Chapter 94 ).

INTERACTIONAL ABILITIES.

Soon after birth, neonates are alert and ready to interact and nurse. This first alert-awake period may be affected by maternal analgesics and anesthetics or fetal hypoxia. Nearsighted neonates have a fixed focal length of 8–12 in, approximately the distance from the breast to the mother’s face, as well as an inborn visual preference for faces. Hearing is well developed, and infants preferentially turn toward a female voice. These innate abilities and predilections increase the likelihood that when a mother gazes at her newborn, the baby will gaze back. The initial period of social interaction, usually lasting about 40 min, is followed by a period of somnolence. After that, briefer periods of alertness or excitation alternate with sleep. If a mother misses her baby’s first alert-awake period, she may not experience as long a period of social interaction for several days.

MODULATION OF AROUSAL.

Adaptation to extrauterine life requires rapid and profound physiologic changes, including aeration of the lungs, rerouting of the circulation, and activation of the intestinal tract. The necessary behavioral changes are no less profound. To obtaiourishment, to avoid hypo- and hyperthermia, and to ensure safety, neonates must react appropriately to an expanded range of sensory stimuli. Infants must become aroused in response to stimulation, but not so overaroused that their behavior becomes disorganized. Underaroused infants are not able to feed and interact; overaroused infants show signs of autonomic instability, including flushing or mottling, perioral pallor, hiccupping, vomiting, uncontrolled limb movements, and inconsolable crying.

BEHAVIORAL STATES.

The organization of infant behavior into discrete behavioral states may reflect an infant’s inborn ability to regulate arousal. Six states have been described: quiet sleep, active sleep, drowsy, alert, fussy, and crying. In the alert state, infants visually fixate on objects or faces and follow them horizontally and (within a month) vertically; they also reliably turn toward a novel sound, as if searching for its source. When overstimulated, they may calm themselves by looking away, yawning, or sucking on their lips or hands, thereby increasing parasympathetic activity and reducing sympathetic nervous activity. The behavioral state determines an infant’s muscle tone, spontaneous movement, electroencephalogram pattern, and response to stimuli. In active sleep, an infant may show progressively less reaction to a repeated heel stick (habituation), whereas in the drowsy state, the same stimulus may push a child into fussing or crying.

MUTUAL REGULATION.

Parents actively participate in an infant’s state regulation, alternately stimulating and soothing. In turn, they are regulated by the infant’s signals, responding to cries of hunger with a letdown of milk (or with a bottle). Such interactions constitute a system directed toward furthering the infant’s physiologic homeostasis and physical growth. At the same time, they form the basis for the emerging psychologic relationship between parent and child. Infants come to associate the presence of the parent with the pleasurable reduction of tension (as in feeding) and show this preference by calming more quickly for their mother than for a stranger. This response, in turn, strengthens a mother’s sense of efficacy and her connection with her baby.

IMPLICATIONS FOR THE PEDIATRICIAN

The pediatrician can support healthy newborn development in several ways.

OPTIMAL PRACTICES.

A prenatal pediatric visit allows pediatricians to assess potential threats to bonding (a tense spousal relationship) and sources of social support. Supportive hospital policies include the use of birthing rooms rather than operating suites and delivery rooms; encouragement for the father or a trusted relative or friend to remain with the mother during labor or the provision of a professional doula; the practice of giving the newborn infant to the mother immediately after drying and a brief assessment; placement of the newborn in the mother’s room rather than in a central nursery; and avoiding in-hospital distribution of infant formula. Such policies (Baby Friendly Hospital) have been shown to significantly increase breast-feeding rates (see Chapter 94 ). After discharge, home visits by nurses and lactation counselors can reduce early feeding problems and identify emerging medical conditions in either mother or baby. Infants requiring transport to another hospital should be brought to see the mother first, if at all possible. On discharge home, fathers can shield mothers from unnecessary visits and calls and take over household duties, allowing mothers and infants time to get to know each other without distractions. The first office visit should occur during the first 2 wk after discharge to determine how smoothly the mother and infant are making the transition to life at home. Babies who are discharged early, those who are breast-feeding, and those who are at risk for jaundice should be seen 2 to 5 days after discharge.

ASSESSING PARENT-INFANT INTERACTIONS.

During a feeding or when infants are alert and face-to-face with their parents, it is normal for them to appear absorbed in one another. Infants who become overstimulated by the mother’s voice or activity may turn away or close their eyes, leading to a premature termination of the encounter. Alternatively, the infant may be ready to interact, whereas the mother may appear preoccupied. Asking a new mother about her own emotional state, and inquiring specifically about a history of depression, facilitates referral for therapy, which may provide long-term benefits to the child. Pediatricians may detect postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) at well child visits during the first year ( Table 7-2 ).

 

THE INFANT’S ROLE IN MATERNAL-INFANT ATTACHMENT

The in utero environment contributes greatly but not completely to the future growth and development of the fetus. Abnormalities in maternal-fetal placental circulation and maternal glucose metabolism or the presence of maternal infection can result in abnormal fetal growth. Infants may be small or large for gestational age as a result. These abnormal growth patterns not only predispose infants to an increased requirement for medical intervention but also may affect their ability to respond behaviorally to their parents.

PHYSICAL EXAMINATION.

Examination of the newborn should include an evaluation of growth and an observation of behavior. The average term newborn weighs approximately 3.4 kg (7½ lb); boys are slightly heavier than girls are. The average length and head circumference are about 50 cm (20 in) and 35 cm (14 in), respectively, in term infants. Each newborn’s growth parameters should be plotted on growth curves specific for that infant’s gestational age to determine the appropriateness of size. The infant’s response to being examined may be useful in assessing its vigor, alertness, and tone. Observing how the parents handle their infant, their comfort and affection, is also important. The order of the physical examination should be from the least to the most intrusive maneuver. Assessing visual tracking and response to sound and noting changes of tone with level of activity and alertness are very helpful. Performing this examination and sharing impression with parents is an important opportunity to facilitate bonding (see Chapter 94 ).

INTERACTIONAL ABILITIES.

Soon after birth, neonates are alert and ready to interact and nurse. This first alert-awake period may be affected by maternal analgesics and anesthetics or fetal hypoxia. Nearsighted neonates have a fixed focal length of 8–12 in, approximately the distance from the breast to the mother’s face, as well as an inborn visual preference for faces. Hearing is well developed, and infants preferentially turn toward a female voice. These innate abilities and predilections increase the likelihood that when a mother gazes at her newborn, the baby will gaze back. The initial period of social interaction, usually lasting about 40 min, is followed by a period of somnolence. After that, briefer periods of alertness or excitation alternate with sleep. If a mother misses her baby’s first alert-awake period, she may not experience as long a period of social interaction for several days.

MODULATION OF AROUSAL.

Adaptation to extrauterine life requires rapid and profound physiologic changes, including aeration of the lungs, rerouting of the circulation, and activation of the intestinal tract. The necessary behavioral changes are no less profound. To obtaiourishment, to avoid hypo- and hyperthermia, and to ensure safety, neonates must react appropriately to an expanded range of sensory stimuli. Infants must become aroused in response to stimulation, but not so overaroused that their behavior becomes disorganized. Underaroused infants are not able to feed and interact; overaroused infants show signs of autonomic instability, including flushing or mottling, perioral pallor, hiccupping, vomiting, uncontrolled limb movements, and inconsolable crying.

BEHAVIORAL STATES.

The organization of infant behavior into discrete behavioral states may reflect an infant’s inborn ability to regulate arousal. Six states have been described: quiet sleep, active sleep, drowsy, alert, fussy, and crying. In the alert state, infants visually fixate on objects or faces and follow them horizontally and (within a month) vertically; they also reliably turn toward a novel sound, as if searching for its source. When overstimulated, they may calm themselves by looking away, yawning, or sucking on their lips or hands, thereby increasing parasympathetic activity and reducing sympathetic nervous activity. The behavioral state determines an infant’s muscle tone, spontaneous movement, electroencephalogram pattern, and response to stimuli. In active sleep, an infant may show progressively less reaction to a repeated heel stick (habituation), whereas in the drowsy state, the same stimulus may push a child into fussing or crying.

MUTUAL REGULATION.

Parents actively participate in an infant’s state regulation, alternately stimulating and soothing. In turn, they are regulated by the infant’s signals, responding to cries of hunger with a letdown of milk (or with a bottle). Such interactions constitute a system directed toward furthering the infant’s physiologic homeostasis and physical growth. At the same time, they form the basis for the emerging psychologic relationship between parent and child. Infants come to associate the presence of the parent with the pleasurable reduction of tension (as in feeding) and show this preference by calming more quickly for their mother than for a stranger. This response, in turn, strengthens a mother’s sense of efficacy and her connection with her baby.

IMPLICATIONS FOR THE PEDIATRICIAN

The pediatrician can support healthy newborn development in several ways.

OPTIMAL PRACTICES.

A prenatal pediatric visit allows pediatricians to assess potential threats to bonding (a tense spousal relationship) and sources of social support. Supportive hospital policies include the use of birthing rooms rather than operating suites and delivery rooms; encouragement for the father or a trusted relative or friend to remain with the mother during labor or the provision of a professional doula; the practice of giving the newborn infant to the mother immediately after drying and a brief assessment; placement of the newborn in the mother’s room rather than in a central nursery; and avoiding in-hospital distribution of infant formula. Such policies (Baby Friendly Hospital) have been shown to significantly increase breast-feeding rates (see Chapter 94 ). After discharge, home visits by nurses and lactation counselors can reduce early feeding problems and identify emerging medical conditions in either mother or baby. Infants requiring transport to another hospital should be brought to see the mother first, if at all possible. On discharge home, fathers can shield mothers from unnecessary visits and calls and take over household duties, allowing mothers and infants time to get to know each other without distractions. The first office visit should occur during the first 2 wk after discharge to determine how smoothly the mother and infant are making the transition to life at home. Babies who are discharged early, those who are breast-feeding, and those who are at risk for jaundice should be seen 2 to 5 days after discharge.

ASSESSING PARENT-INFANT INTERACTIONS.

During a feeding or when infants are alert and face-to-face with their parents, it is normal for them to appear absorbed in one another. Infants who become overstimulated by the mother’s voice or activity may turn away or close their eyes, leading to a premature termination of the encounter. Alternatively, the infant may be ready to interact, whereas the mother may appear preoccupied. Asking a new mother about her own emotional state, and inquiring specifically about a history of depression, facilitates referral for therapy, which may provide long-term benefits to the child. Pediatricians may detect postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) at well child visits during the first year ( Table 7-2 ).

 

THE INFANT’S ROLE IN MATERNAL-INFANT ATTACHMENT

The in utero environment contributes greatly but not completely to the future growth and development of the fetus. Abnormalities in maternal-fetal placental circulation and maternal glucose metabolism or the presence of maternal infection can result in abnormal fetal growth. Infants may be small or large for gestational age as a result. These abnormal growth patterns not only predispose infants to an increased requirement for medical intervention but also may affect their ability to respond behaviorally to their parents.

PHYSICAL EXAMINATION.

Examination of the newborn should include an evaluation of growth and an observation of behavior. The average term newborn weighs approximately 3.4 kg (7½ lb); boys are slightly heavier than girls are. The average length and head circumference are about 50 cm (20 in) and 35 cm (14 in), respectively, in term infants. Each newborn’s growth parameters should be plotted on growth curves specific for that infant’s gestational age to determine the appropriateness of size. The infant’s response to being examined may be useful in assessing its vigor, alertness, and tone. Observing how the parents handle their infant, their comfort and affection, is also important. The order of the physical examination should be from the least to the most intrusive maneuver. Assessing visual tracking and response to sound and noting changes of tone with level of activity and alertness are very helpful. Performing this examination and sharing impression with parents is an important opportunity to facilitate bonding (see Chapter 94 ).

INTERACTIONAL ABILITIES.

Soon after birth, neonates are alert and ready to interact and nurse. This first alert-awake period may be affected by maternal analgesics and anesthetics or fetal hypoxia. Nearsighted neonates have a fixed focal length of 8–12 in, approximately the distance from the breast to the mother’s face, as well as an inborn visual preference for faces. Hearing is well developed, and infants preferentially turn toward a female voice. These innate abilities and predilections increase the likelihood that when a mother gazes at her newborn, the baby will gaze back. The initial period of social interaction, usually lasting about 40 min, is followed by a period of somnolence. After that, briefer periods of alertness or excitation alternate with sleep. If a mother misses her baby’s first alert-awake period, she may not experience as long a period of social interaction for several days.

MODULATION OF AROUSAL.

Adaptation to extrauterine life requires rapid and profound physiologic changes, including aeration of the lungs, rerouting of the circulation, and activation of the intestinal tract. The necessary behavioral changes are no less profound. To obtaiourishment, to avoid hypo- and hyperthermia, and to ensure safety, neonates must react appropriately to an expanded range of sensory stimuli. Infants must become aroused in response to stimulation, but not so overaroused that their behavior becomes disorganized. Underaroused infants are not able to feed and interact; overaroused infants show signs of autonomic instability, including flushing or mottling, perioral pallor, hiccupping, vomiting, uncontrolled limb movements, and inconsolable crying.

BEHAVIORAL STATES.

The organization of infant behavior into discrete behavioral states may reflect an infant’s inborn ability to regulate arousal. Six states have been described: quiet sleep, active sleep, drowsy, alert, fussy, and crying. In the alert state, infants visually fixate on objects or faces and follow them horizontally and (within a month) vertically; they also reliably turn toward a novel sound, as if searching for its source. When overstimulated, they may calm themselves by looking away, yawning, or sucking on their lips or hands, thereby increasing parasympathetic activity and reducing sympathetic nervous activity. The behavioral state determines an infant’s muscle tone, spontaneous movement, electroencephalogram pattern, and response to stimuli. In active sleep, an infant may show progressively less reaction to a repeated heel stick (habituation), whereas in the drowsy state, the same stimulus may push a child into fussing or crying.

MUTUAL REGULATION.

Parents actively participate in an infant’s state regulation, alternately stimulating and soothing. In turn, they are regulated by the infant’s signals, responding to cries of hunger with a letdown of milk (or with a bottle). Such interactions constitute a system directed toward furthering the infant’s physiologic homeostasis and physical growth. At the same time, they form the basis for the emerging psychologic relationship between parent and child. Infants come to associate the presence of the parent with the pleasurable reduction of tension (as in feeding) and show this preference by calming more quickly for their mother than for a stranger. This response, in turn, strengthens a mother’s sense of efficacy and her connection with her baby.

IMPLICATIONS FOR THE PEDIATRICIAN

The pediatrician can support healthy newborn development in several ways.

OPTIMAL PRACTICES.

A prenatal pediatric visit allows pediatricians to assess potential threats to bonding (a tense spousal relationship) and sources of social support. Supportive hospital policies include the use of birthing rooms rather than operating suites and delivery rooms; encouragement for the father or a trusted relative or friend to remain with the mother during labor or the provision of a professional doula; the practice of giving the newborn infant to the mother immediately after drying and a brief assessment; placement of the newborn in the mother’s room rather than in a central nursery; and avoiding in-hospital distribution of infant formula. Such policies (Baby Friendly Hospital) have been shown to significantly increase breast-feeding rates (see Chapter 94 ). After discharge, home visits by nurses and lactation counselors can reduce early feeding problems and identify emerging medical conditions in either mother or baby. Infants requiring transport to another hospital should be brought to see the mother first, if at all possible. On discharge home, fathers can shield mothers from unnecessary visits and calls and take over household duties, allowing mothers and infants time to get to know each other without distractions. The first office visit should occur during the first 2 wk after discharge to determine how smoothly the mother and infant are making the transition to life at home. Babies who are discharged early, those who are breast-feeding, and those who are at risk for jaundice should be seen 2 to 5 days after discharge.

ASSESSING PARENT-INFANT INTERACTIONS.

During a feeding or when infants are alert and face-to-face with their parents, it is normal for them to appear absorbed in one another. Infants who become overstimulated by the mother’s voice or activity may turn away or close their eyes, leading to a premature termination of the encounter. Alternatively, the infant may be ready to interact, whereas the mother may appear preoccupied. Asking a new mother about her own emotional state, and inquiring specifically about a history of depression, facilitates referral for therapy, which may provide long-term benefits to the child. Pediatricians may detect postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) at well child visits during the first year ( Table 7-2 ).

 

AGE 0–2 MONTHS

In this period, the infant experiences tremendous growth. Physiologic changes allow the establishment of effective feeding routines and a predictable sleep-wake cycle. The social interactions that occur as parents and infants accomplish these tasks lay the foundation for cognitive and emotional development.

PHYSICAL DEVELOPMENT.

A newborn’s weight may decrease 10% below birthweight in the 1st wk as a result of excretion of excess extravascular fluid and limited intake. Nutrition improves as colostrum is replaced by higher-fat breast milk, as infants learn to latch on and suck more efficiently, and as mothers become more comfortable with feeding techniques. Infants regain or exceed birth weight by 2 wk of age and should grow at approximately 30 g (1 oz)/day during the 1st mo (see Table 14-1 ). This is the period of fastest postnatal growth. Limb movements consist largely of uncontrolled writhing, with apparently purposeless opening and closing of the hands. Smiling occurs involuntarily. Eye gaze, head turning, and sucking are under better control and thus can be used to demonstrate infant perception and cognition. An infant’s preferential turning toward the mother’s voice is evidence of recognition memory.

Six behavioral states have been described (see Chapter 7 ). Initially, sleep and wakefulness are evenly distributed throughout the 24 hr day ( Fig. 8-1 ). Neurologic maturation accounts for the consolidation of sleep into blocks of 5 or 6 hr at night, with brief awake, feeding periods. Learning also occurs; infants whose parents are consistently more interactive and stimulating during the day learn to concentrate their sleeping during the night.

 

COGNITIVE DEVELOPMENT.

Caretaking activities provide visual, tactile, olfactory, and auditory stimuli; all of these support the development of cognition. Infants habituate to the familiar, attending less and less to repeated stimuli and increasing their attention when the stimulus changes. Infants can differentiate among patterns, colors, and consonants. They can recognize facial expressions (smiles) as similar, even when they appear on different faces. They also can match abstract properties of stimuli, such as contour, intensity, or temporal pattern, across sensory modalities. For example, infants at 2 mo of age can discriminate rhythmic patterns iative vs. non-native language. Infants appear to seek stimuli actively, as though satisfying an innate need to make sense of the world. These phenomena point to the integration of sensory inputs in the central nervous system.

EMOTIONAL DEVELOPMENT.

The infant is dependent on the environment to meet his or her needs. The consistent availability of a trusted adult to meet the infant’s urgent needs creates the conditions for secure attachment. Basic trust vs mistrust, the first of Erikson’s psychosocial stages, depends on attachment and reciprocal maternal bonding. Crying occurs in response to stimuli that may be obvious (a soiled diaper), but are often obscure. Infants who are consistently picked up and held in response to distress cry less at 1 yr and show less aggressive behavior at 2 yr. Cross-cultural studies show that in societies in which infants are carried close to the mother, babies cry less than in societies in which babies are only periodically carried. Crying normally peaks at about 6 wk of age, when healthy infants cry up to 3 hr/day, then decreases to 1 hr or less by 3 mo.

The emotional significance of any experience depends on both the individual child’s temperament and the parent’s responses (see Table 6-1 ). Consider the impact of different feeding schedules. Hunger generates increasing tension; as the urgency peaks, the infant cries, the parent offers the bottle or breast, and the tension dissipates. Infants fed “on demand” consistently experience this link between their distress, the arrival of the parent, and relief from hunger. Most infants fed on a fixed schedule quickly adapt their hunger cycle to the schedule. Those who cannot because they are temperamentally prone to irregular biologic rhythms experience periods of unrelieved hunger as well as unwanted feedings when they already feel full. Similarly, infants fed at the parents’ convenience, with neither attention to the infant’s hunger cues nor a fixed schedule, may not consistently experience feeding as the pleasurable reduction of tension. These infants often show increased irritability and physiologic instability (spitting, diarrhea, poor weight gain) as well as later behavioral problems.

IMPLICATIONS FOR PARENTS AND PEDIATRICIANS.

Success or failure in establishing feeding and sleep cycles determines parents’ feelings of efficacy. When things go well, the parents’ anxiety and ambivalence, as well as the exhaustion of the early weeks, decrease. Infant issues (colic) or familial conflict will prevent this from occurring. With physical recovery from delivery and endocrinologic normalization, the mild postpartum depression that affects many mothers passes. If the mother continues to feel sad, overwhelmed, and anxious, the possibility of moderate to severe postpartum depression, found in 10% of postpartum women, needs to be considered. Major depression that arises during pregnancy or in the postpartum period threatens the mother-child relationship and is a risk factor for later cognitive and behavioral problems. The pediatrician may be the first professional to encounter the depressed mother and should be instrumental in assisting her in seeking treatment (see Chapter 7 ).

AGE 2–6 MONTHS

At about 2 mo, the emergence of voluntary (social) smiles and increasing eye contact mark a change in the parent-child relationship, heightening the parents’ sense of being loved back. During the next months, an infant’s range of motor and social control and cognitive engagement increases dramatically. Mutual regulation takes the form of complex social interchanges, resulting in strong mutual attachment and enjoyment. Parents are less fatigued.

PHYSICAL DEVELOPMENT.

Between 3 and 4 mo of age, the rate of growth slows to approximately 20 g/day (see Table 14-1 and Figs. 9-1 and 9-2 ). By 4 mo, birth weight is doubled. Early reflexes that limited voluntary movement recede. Disappearance of the asymmetric tonic neck reflex means that infants can begin to examine objects in the midline and manipulate them with both hands (see Chapter 591 ). Waning of the early grasp reflex allows infants both to hold objects and to let them go voluntarily. A novel object may elicit purposeful, although inefficient, reaching. The quality of spontaneous movements also changes, from larger writhing to smaller, circular movements that have been described as “fidgety.” Abnormal or absent fidgety movements may constitute a risk factor for later neurologic abnormalities.

Increasing control of truncal flexion makes intentional rolling possible. Once infants can hold their heads steady while sitting, they can gaze across at things rather than merely looking up at them, and can begin taking food from a spoon. At the same time, maturation of the visual system allows greater depth perception.

In this period, infants achieve stable state regulation and regular sleep-wake cycles. Total sleep requirements are approximately 14–16 hr/24 hr, with about 9–10 hr concentrated at night and 2 naps/day. About 70% of infants sleep for a 6–8 hr stretch by age 6 mo (see Fig. 8-1 ). By 4–6 mo, the sleep electroencephalogram shows a mature pattern, with demarcation of rapid eye movement (REM) and 4 stages of non-REM sleep. The sleep cycle remains shorter than in adults (50–60 min vs approximately 90 min). As a result, infants arouse to light sleep or wake frequently during the night, setting the stage for behavioral sleep problems (see Chapter 18 ).

COGNITIVE DEVELOPMENT.

The overall effect of these developments is a qualitative change. At 4 mo of age, infants are described as “hatching” socially, becoming interested in a wider world. During feeding, infants no longer focus exclusively on the mother, but become distracted. In the mother’s arms, the infant may literally turn around, preferring to face outward.

Infants at this age also explore their own bodies, staring intently at their hands, vocalizing, blowing bubbles, and touching their ears, cheeks, and genitals. These explorations represent an early stage in the understanding of cause and effect as infants learn that voluntary muscle movements generate predictable tactile and visual sensations. They also have a role in the emergence of a sense of self, separate from the mother. This is the first stage of personality development. Infants come to associate certain sensations through frequent repetition. The proprioceptive feeling of holding up the hand and wiggling the fingers always accompanies the sight of the fingers moving. Such “self” sensations are consistently linked and reproducible at will. In contrast, sensations that are associated with “other” occur with less regularity and in varying combinations. The sound, smell, and feel of the mother sometimes appear promptly in response to crying, but sometimes do not. The satisfaction that the mother or another loving adult provides continues the process of attachment.

EMOTIONAL DEVELOPMENT AND COMMUNICATION.

Babies interact with increasing sophistication and range. The primary emotions of anger, joy, interest, fear, disgust, and surprise appear in appropriate contexts as distinct facial expressions. When face-to-face, the infant and a trusted adult match affective expressions (smiling or surprise) about 30% of the time. Initiating “games” (facial imitation, singing, hand games) increases social development. Such face-to-face behavior reveals the infant’s ability to share emotional states, the first step in the development of communication. Infants of depressed parents show a different pattern, spending less time in coordinated movement with their parents and making fewer efforts to re-engage. Rather than anger, they show sadness and a loss of energy when the parents continue to be unavailable.

IMPLICATIONS FOR PARENTS AND PEDIATRICIANS.

Motor and sensory maturation makes infants at 3–6 mo exciting and interactive. Some parents experience their 4 mo old child’s outward turning as a rejection, secretly fearing that their infants no longer love them. For most parents, however, this is a happy period. Most parents excitedly report that they can hold “conversations” with their infants, taking turns vocalizing and listening. Pediatricians share in the enjoyment, as the baby coos, makes eye contact, and moves rhythmically. If this visit does not feel joyful and relaxed, causes such as social stress, family dysfunction, parental mental illness, or problems in the infant-parent relationship should be considered. Parents can be reassured that responding to an infant’s emotional needs cannot “spoil” him or her. Giving vaccines and drawing blood while the child is seated on the parent’s lap increases pain tolerance.

AGE 6–12 MONTHS

With achievement of the sitting position, increased mobility, and new skills to explore the world around them, 6–12 mo old infants show advances in cognitive understanding and communicative competence, and there are new tensions around the themes of attachment and separation. Infants develop will and intentions, characteristics that most parents welcome, but still find challenging to manage.

PHYSICAL DEVELOPMENT.

Growth slows more (see Table 14-1 and Figs. 9-1 and 9-2 ). By the 1st birthday, birthweight has tripled, length has increased by 50%, and head circumference has increased by 10 cm. The ability to sit unsupported (6–7 mo) and to pivot while sitting (around 9–10 mo) provides increasing opportunities to manipulate several objects at a time and to experiment with novel combinations of objects. These explorations are aided by the emergence of a thumb-finger grasp (8–9 mo) and a neat pincer grasp by 12 mo. Many infants begin crawling and pulling to stand around 8 mo, followed by cruising. Some walk by 1 yr. Motor achievements correlate with increasing myelinization and cerebellar growth. These gross motor skills expand infants’ exploratory range and create new physical dangers as well as opportunities for learning. Tooth eruption occurs, usually starting with the mandibular central incisors ( Table 8-3 ). Tooth development reflects skeletal maturation and bone age, although there is wide individual variation ( Table 8-4 ).

TABLE 8-3   — Chronology of Human Dentition of Primary or Deciduous and Secondary or Permanent Teeth

	CALCIFICATION		AGE AT ERUPTION		AGE AT SHEDDING
	Begins At	Complete At	Maxillary	Mandibular	Maxillary	Mandibular
PRIMARY TEETH
Central incisors	5th fetal mo	18–24 mo	6–8 mo	5–7 mo	7–8 yr	6–7 yr
Lateral incisors	5th fetal mo	18–24 mo	8–11 mo	7–10 mo	8–9 yr	7–8 yr
Cuspids (canines)	6th fetal mo	30–36 mo	16–20 mo	16–20 mo	11–12 yr	9–11 yr
First molars	5th fetal mo	24–30 mo	10–16 mo	10–16 mo	10–12 yr	10–12 yr
Second molars	6th fetal mo	36 mo	20–30 mo	20–30 mo	10–12 yr	11–13 yr
SECONDARY TEETH
Central incisors	3–4 mo	9–10 yr	7–8 yr	6–7 yr
Lateral incisors	Max, 10–12 mo	10–11 yr	8–9 yr	7–8 yr
	Mand, 3–4 mo
Cuspids (canines)	4–5 mo	12–15 yr	11–12 yr	9–11 yr
First premolars (bicuspids)	18–21 mo	12–13 yr	10–11 yr	10–12 yr
Second premolars (bicuspids)	24–30 mo	12–14 yr	10–12 yr	11–13 yr
First molars	Birth	9–10 yr	6–7 yr	6–7 yr
Second molars	30–36 mo	14–16 yr	12–13 yr	12–13 yr
Third molars	Max, 7–9 yr	18–25 yr	17–22 yr	17–22 yr
	Mand, 8–10 yr

Adapted from chart prepared by P.K. Losch, Harvard School of Dental Medicine, who provided the data for this table. Mand, mandibular; Max, maxillary.

 

TABLE 8-4   — Time of Appearance in Roentgenograms of Centers of Ossification in Infancy and Childhood

BOYS—AGE AT APPEARANCE[*]	BONES AND EPIPHYSEAL CENTERS	GIRLS—AGE AT APPEARANCE[*]
HUMERUS, HEAD
3 wk		3 wk
CARPAL BONES
2 mo ± 2 mo	Capitate	2 mo ± 2 mo
3 mo ± 2 mo	Hamate	2 mo ± 2 mo
30 mo ± 16 mo	Triangular[†]	21 mo ± 14 mo
42 mo ± 19 mo	Lunate[†]	34 mo ± 13 mo
67 mo ± 19 mo	Trapezium[†]	47 mo ± 14 mo
69 mo ± 15 mo	Trapezoid[†]	49 mo ± 12 mo
66 mo ± 15 mo	Scaphoid[†]	51 mo ± 12 mo
No standards available	Pisiform[†]	No standards available
METACARPAL BONES
18 mo ± 5 mo	II	12 mo ± 3 mo
20 mo ± 5 mo	III	13 mo ± 3 mo
23 mo ± 6 mo	IV	15 mo ± 4 mo
26 mo ± 7 mo	V	16 mo ± 5 mo
32 mo ± 9 mo	I	18 mo ± 5 mo
FINGERS (EPIPHYSES)
16 mo ± 4 mo	Proximal phalanx, 3rd finger	10 mo ± 3 mo
16 mo ± 4 mo	Proximal phalanx, 2nd finger	11 mo ± 3 mo
17 mo ± 5 mo	Proximal phalanx, 4th finger	11 mo ± 3 mo
19 mo ± 7 mo	Distal phalanx, 1st finger	12 mo ± 4 mo
21 mo ± 5 mo	Proximal phalanx, 5th finger	14 mo ± 4 mo
24 mo ± 6 mo	Middle phalanx, 3rd finger	15 mo ± 5 mo
24 mo ± 6 mo	Middle phalanx, 4th finger	15 mo ± 5 mo
26 mo ± 6 mo	Middle phalanx, 2nd finger	16 mo ± 5 mo
28 mo ± 6 mo	Distal phalanx, 3rd finger	18 mo ± 4 mo
28 mo ± 6 mo	Distal phalanx, 4th finger	18 mo ± 5 mo
32 mo ± 7 mo	Proximal phalanx, 1st finger	20 mo ± 5 mo
37 mo ± 9 mo	Distal phalanx, 5th finger	23 mo ± 6 mo
37 mo ± 8 mo	Distal phalanx, 2nd finger	23 mo ± 6 mo
39 mo ± 10 mo	Middle phalanx, 5th finger	22 mo ± 7 mo
152 mo ± 18 mo	Sesamoid (adductor pollicis)	121 mo ± 13 mo
HIP AND KNEE
Usually present at birth	Femur, distal	Usually present at birth
Usually present at birth	Tibia, proximal	Usually present at birth
4 mo ± 2 mo	Femur, head	4 mo ± 2 mo
46 mo ± 11 mo	Patella	29 mo ± 7 mo
FOOT AND ANKLE[‡]
Values represent mean ± standard deviation, when applicable.

The norms present a composite of published data from the Fels Research Institute, Yellow Springs, OH (Pyle SI, Sontag L: Am J Roentgenol 1943; 49:102), and unpublished data from the Brush Foundation, Case Western Reserve University, Cleveland, OH, and the Harvard School of Public Health, Boston, MA. Compiled by Lieb, Buehl, and Pyle.

*	To nearest month.
†	Except for the capitate and hamate bones, the variability of carpal centers is too great to make them very useful clinically.
‡	Standards for the foot are available, but normal variation is wide, including some familial variants, so this area is of little clinical use.

 

 

COGNITIVE DEVELOPMENT.

The 6 mo old infant has discovered his hands and will soon learn to manipulate objects. At first, everything goes into the mouth. In time, novel objects are picked up, inspected, passed from hand to hand, banged, dropped, and then mouthed. Each action represents a nonverbal idea about what things are for (in Piagetian terms, a schema). The complexity of an infant’s play, how many different schemata are brought to bear, is a useful index of cognitive development at this age. The pleasure, persistence, and energy with which infants tackle these challenges suggest the existence of an intrinsic drive or mastery motivation. Mastery behavior occurs when infants feel secure; those with less secure attachments show limited experimentation and less competence.

A major milestone is the achievement at about 9 mo of object permanence (constancy), the understanding that objects continue to exist, even wheot seen. At 4–7 mo of age, infants look down for a yarn ball that has been dropped, but quickly give up if it is not seen. With object constancy, infants persist in searching, finding objects hidden under a cloth or behind the examiner’s back. Peek-a-boo brings unlimited pleasure as the child magically brings back the other player. Events seem to occur as a result of the child’s own activities.

EMOTIONAL DEVELOPMENT.

The advent of object permanence corresponds with qualitative changes in social and communicative development. Infants look back and forth between an approaching stranger and a parent, and may cling or cry anxiously, demonstrating “stranger anxiety.” Separations often become more difficult. Infants who have been sleeping through the night for months begin to awaken regularly and cry, as though remembering that the parents are in the next room.

A new demand for autonomy also emerges. Poor weight gain at this age often reflects a struggle between an infant’s emerging independence and parent’s control of the feeding situation. Use of the 2-spoon method of feeding (1 for the child and 1 for the parent), finger foods, and a high chair with a tray table can avert potential problems. Tantrums make their first appearance as the drives for autonomy and mastery come in conflict with parental controls and the infants’ still-limited abilities.

COMMUNICATION.

Infants at 7 mo of age are adept at nonverbal communication, expressing a range of emotions and responding to vocal tone and facial expressions. Around 9 mo of age, infants become aware that emotions can be shared between people; they show parents toys as a way of sharing their happy feelings. Between 8 and 10 mo of age, babbling takes on a new complexity, with many syllables (“ba-da-ma”) and inflections that mimic the native language. Infants now lose the ability to distinguish between vocal sounds that are undifferentiated in their native language. Social interaction (attentive adults taking turns vocalizing with the infant) profoundly influences the acquisition and production of new sounds. The first true word (i.e., a sound used consistently to refer to a specific object or person) appears in concert with an infant’s discovery of object permanence. Picture books now provide an ideal context for verbal language acquisition. With a familiar book as a shared focus of attention, a parent and child engage in repeated cycles of pointing and labeling, with elaboration and feedback by the parent.

IMPLICATIONS FOR PARENTS AND PEDIATRICIANS.

With the developmental reorganization that occurs around 9 mo of age, previously resolved issues of feeding and sleeping re-emerge. Pediatricians can prepare parents at the 6 mo visit so that these problems can be understood as the result of developmental progress and not regression. Parents should be encouraged to plan ahead for necessary, and inevitable, separations (e.g., baby sitter, daycare). Routine preparations may make these separations easier. Introduction of a “transitional object” may allow the infant to self-comfort in the parents’ absence.

Infants’ wariness of strangers often makes the 9 mo examination difficult, particularly if the infant is temperamentally prone to react negatively to unfamiliar situations. Initially, the pediatrician should avoid direct eye contact with the child. Time spent talking with the parent and introducing the child to a small, washable toy will be rewarded with more cooperation. The examination can be continued on the parent’s lap when feasible.

 

AGE 0–2 MONTHS

In this period, the infant experiences tremendous growth. Physiologic changes allow the establishment of effective feeding routines and a predictable sleep-wake cycle. The social interactions that occur as parents and infants accomplish these tasks lay the foundation for cognitive and emotional development.

PHYSICAL DEVELOPMENT.

A newborn’s weight may decrease 10% below birthweight in the 1st wk as a result of excretion of excess extravascular fluid and limited intake. Nutrition improves as colostrum is replaced by higher-fat breast milk, as infants learn to latch on and suck more efficiently, and as mothers become more comfortable with feeding techniques. Infants regain or exceed birth weight by 2 wk of age and should grow at approximately 30 g (1 oz)/day during the 1st mo (see Table 14-1 ). This is the period of fastest postnatal growth. Limb movements consist largely of uncontrolled writhing, with apparently purposeless opening and closing of the hands. Smiling occurs involuntarily. Eye gaze, head turning, and sucking are under better control and thus can be used to demonstrate infant perception and cognition. An infant’s preferential turning toward the mother’s voice is evidence of recognition memory.

Six behavioral states have been described (see Chapter 7 ). Initially, sleep and wakefulness are evenly distributed throughout the 24 hr day ( Fig. 8-1 ). Neurologic maturation accounts for the consolidation of sleep into blocks of 5 or 6 hr at night, with brief awake, feeding periods. Learning also occurs; infants whose parents are consistently more interactive and stimulating during the day learn to concentrate their sleeping during the night.

 

COGNITIVE DEVELOPMENT.

Caretaking activities provide visual, tactile, olfactory, and auditory stimuli; all of these support the development of cognition. Infants habituate to the familiar, attending less and less to repeated stimuli and increasing their attention when the stimulus changes. Infants can differentiate among patterns, colors, and consonants. They can recognize facial expressions (smiles) as similar, even when they appear on different faces. They also can match abstract properties of stimuli, such as contour, intensity, or temporal pattern, across sensory modalities. For example, infants at 2 mo of age can discriminate rhythmic patterns iative vs. non-native language. Infants appear to seek stimuli actively, as though satisfying an innate need to make sense of the world. These phenomena point to the integration of sensory inputs in the central nervous system.

EMOTIONAL DEVELOPMENT.

The infant is dependent on the environment to meet his or her needs. The consistent availability of a trusted adult to meet the infant’s urgent needs creates the conditions for secure attachment. Basic trust vs mistrust, the first of Erikson’s psychosocial stages, depends on attachment and reciprocal maternal bonding. Crying occurs in response to stimuli that may be obvious (a soiled diaper), but are often obscure. Infants who are consistently picked up and held in response to distress cry less at 1 yr and show less aggressive behavior at 2 yr. Cross-cultural studies show that in societies in which infants are carried close to the mother, babies cry less than in societies in which babies are only periodically carried. Crying normally peaks at about 6 wk of age, when healthy infants cry up to 3 hr/day, then decreases to 1 hr or less by 3 mo.

The emotional significance of any experience depends on both the individual child’s temperament and the parent’s responses (see Table 6-1 ). Consider the impact of different feeding schedules. Hunger generates increasing tension; as the urgency peaks, the infant cries, the parent offers the bottle or breast, and the tension dissipates. Infants fed “on demand” consistently experience this link between their distress, the arrival of the parent, and relief from hunger. Most infants fed on a fixed schedule quickly adapt their hunger cycle to the schedule. Those who cannot because they are temperamentally prone to irregular biologic rhythms experience periods of unrelieved hunger as well as unwanted feedings when they already feel full. Similarly, infants fed at the parents’ convenience, with neither attention to the infant’s hunger cues nor a fixed schedule, may not consistently experience feeding as the pleasurable reduction of tension. These infants often show increased irritability and physiologic instability (spitting, diarrhea, poor weight gain) as well as later behavioral problems.

IMPLICATIONS FOR PARENTS AND PEDIATRICIANS.

Success or failure in establishing feeding and sleep cycles determines parents’ feelings of efficacy. When things go well, the parents’ anxiety and ambivalence, as well as the exhaustion of the early weeks, decrease. Infant issues (colic) or familial conflict will prevent this from occurring. With physical recovery from delivery and endocrinologic normalization, the mild postpartum depression that affects many mothers passes. If the mother continues to feel sad, overwhelmed, and anxious, the possibility of moderate to severe postpartum depression, found in 10% of postpartum women, needs to be considered. Major depression that arises during pregnancy or in the postpartum period threatens the mother-child relationship and is a risk factor for later cognitive and behavioral problems. The pediatrician may be the first professional to encounter the depressed mother and should be instrumental in assisting her in seeking treatment (see Chapter 7 ).

AGE 2–6 MONTHS

At about 2 mo, the emergence of voluntary (social) smiles and increasing eye contact mark a change in the parent-child relationship, heightening the parents’ sense of being loved back. During the next months, an infant’s range of motor and social control and cognitive engagement increases dramatically. Mutual regulation takes the form of complex social interchanges, resulting in strong mutual attachment and enjoyment. Parents are less fatigued.

PHYSICAL DEVELOPMENT.

Between 3 and 4 mo of age, the rate of growth slows to approximately 20 g/day (see Table 14-1 and Figs. 9-1 and 9-2 ). By 4 mo, birth weight is doubled. Early reflexes that limited voluntary movement recede. Disappearance of the asymmetric tonic neck reflex means that infants can begin to examine objects in the midline and manipulate them with both hands (see Chapter 591 ). Waning of the early grasp reflex allows infants both to hold objects and to let them go voluntarily. A novel object may elicit purposeful, although inefficient, reaching. The quality of spontaneous movements also changes, from larger writhing to smaller, circular movements that have been described as “fidgety.” Abnormal or absent fidgety movements may constitute a risk factor for later neurologic abnormalities.

Increasing control of truncal flexion makes intentional rolling possible. Once infants can hold their heads steady while sitting, they can gaze across at things rather than merely looking up at them, and can begin taking food from a spoon. At the same time, maturation of the visual system allows greater depth perception.

In this period, infants achieve stable state regulation and regular sleep-wake cycles. Total sleep requirements are approximately 14–16 hr/24 hr, with about 9–10 hr concentrated at night and 2 naps/day. About 70% of infants sleep for a 6–8 hr stretch by age 6 mo (see Fig. 8-1 ). By 4–6 mo, the sleep electroencephalogram shows a mature pattern, with demarcation of rapid eye movement (REM) and 4 stages of non-REM sleep. The sleep cycle remains shorter than in adults (50–60 min vs approximately 90 min). As a result, infants arouse to light sleep or wake frequently during the night, setting the stage for behavioral sleep problems (see Chapter 18 ).

COGNITIVE DEVELOPMENT.

The overall effect of these developments is a qualitative change. At 4 mo of age, infants are described as “hatching” socially, becoming interested in a wider world. During feeding, infants no longer focus exclusively on the mother, but become distracted. In the mother’s arms, the infant may literally turn around, preferring to face outward.

Infants at this age also explore their own bodies, staring intently at their hands, vocalizing, blowing bubbles, and touching their ears, cheeks, and genitals. These explorations represent an early stage in the understanding of cause and effect as infants learn that voluntary muscle movements generate predictable tactile and visual sensations. They also have a role in the emergence of a sense of self, separate from the mother. This is the first stage of personality development. Infants come to associate certain sensations through frequent repetition. The proprioceptive feeling of holding up the hand and wiggling the fingers always accompanies the sight of the fingers moving. Such “self” sensations are consistently linked and reproducible at will. In contrast, sensations that are associated with “other” occur with less regularity and in varying combinations. The sound, smell, and feel of the mother sometimes appear promptly in response to crying, but sometimes do not. The satisfaction that the mother or another loving adult provides continues the process of attachment.

EMOTIONAL DEVELOPMENT AND COMMUNICATION.

Babies interact with increasing sophistication and range. The primary emotions of anger, joy, interest, fear, disgust, and surprise appear in appropriate contexts as distinct facial expressions. When face-to-face, the infant and a trusted adult match affective expressions (smiling or surprise) about 30% of the time. Initiating “games” (facial imitation, singing, hand games) increases social development. Such face-to-face behavior reveals the infant’s ability to share emotional states, the first step in the development of communication. Infants of depressed parents show a different pattern, spending less time in coordinated movement with their parents and making fewer efforts to re-engage. Rather than anger, they show sadness and a loss of energy when the parents continue to be unavailable.

IMPLICATIONS FOR PARENTS AND PEDIATRICIANS.

Motor and sensory maturation makes infants at 3–6 mo exciting and interactive. Some parents experience their 4 mo old child’s outward turning as a rejection, secretly fearing that their infants no longer love them. For most parents, however, this is a happy period. Most parents excitedly report that they can hold “conversations” with their infants, taking turns vocalizing and listening. Pediatricians share in the enjoyment, as the baby coos, makes eye contact, and moves rhythmically. If this visit does not feel joyful and relaxed, causes such as social stress, family dysfunction, parental mental illness, or problems in the infant-parent relationship should be considered. Parents can be reassured that responding to an infant’s emotional needs cannot “spoil” him or her. Giving vaccines and drawing blood while the child is seated on the parent’s lap increases pain tolerance.

AGE 6–12 MONTHS

With achievement of the sitting position, increased mobility, and new skills to explore the world around them, 6–12 mo old infants show advances in cognitive understanding and communicative competence, and there are new tensions around the themes of attachment and separation. Infants develop will and intentions, characteristics that most parents welcome, but still find challenging to manage.

PHYSICAL DEVELOPMENT.

Growth slows more (see Table 14-1 and Figs. 9-1 and 9-2 ). By the 1st birthday, birthweight has tripled, length has increased by 50%, and head circumference has increased by 10 cm. The ability to sit unsupported (6–7 mo) and to pivot while sitting (around 9–10 mo) provides increasing opportunities to manipulate several objects at a time and to experiment with novel combinations of objects. These explorations are aided by the emergence of a thumb-finger grasp (8–9 mo) and a neat pincer grasp by 12 mo. Many infants begin crawling and pulling to stand around 8 mo, followed by cruising. Some walk by 1 yr. Motor achievements correlate with increasing myelinization and cerebellar growth. These gross motor skills expand infants’ exploratory range and create new physical dangers as well as opportunities for learning. Tooth eruption occurs, usually starting with the mandibular central incisors ( Table 8-3 ). Tooth development reflects skeletal maturation and bone age, although there is wide individual variation ( Table 8-4 ).

TABLE 8-3   — Chronology of Human Dentition of Primary or Deciduous and Secondary or Permanent Teeth

	CALCIFICATION		AGE AT ERUPTION		AGE AT SHEDDING
	Begins At	Complete At	Maxillary	Mandibular	Maxillary	Mandibular
PRIMARY TEETH
Central incisors	5th fetal mo	18–24 mo	6–8 mo	5–7 mo	7–8 yr	6–7 yr
Lateral incisors	5th fetal mo	18–24 mo	8–11 mo	7–10 mo	8–9 yr	7–8 yr
Cuspids (canines)	6th fetal mo	30–36 mo	16–20 mo	16–20 mo	11–12 yr	9–11 yr
First molars	5th fetal mo	24–30 mo	10–16 mo	10–16 mo	10–12 yr	10–12 yr
Second molars	6th fetal mo	36 mo	20–30 mo	20–30 mo	10–12 yr	11–13 yr
SECONDARY TEETH
Central incisors	3–4 mo	9–10 yr	7–8 yr	6–7 yr
Lateral incisors	Max, 10–12 mo	10–11 yr	8–9 yr	7–8 yr
	Mand, 3–4 mo
Cuspids (canines)	4–5 mo	12–15 yr	11–12 yr	9–11 yr
First premolars (bicuspids)	18–21 mo	12–13 yr	10–11 yr	10–12 yr
Second premolars (bicuspids)	24–30 mo	12–14 yr	10–12 yr	11–13 yr
First molars	Birth	9–10 yr	6–7 yr	6–7 yr
Second molars	30–36 mo	14–16 yr	12–13 yr	12–13 yr
Third molars	Max, 7–9 yr	18–25 yr	17–22 yr	17–22 yr
	Mand, 8–10 yr

Adapted from chart prepared by P.K. Losch, Harvard School of Dental Medicine, who provided the data for this table. Mand, mandibular; Max, maxillary.

 

TABLE 8-4   — Time of Appearance in Roentgenograms of Centers of Ossification in Infancy and Childhood

BOYS—AGE AT APPEARANCE[*]	BONES AND EPIPHYSEAL CENTERS	GIRLS—AGE AT APPEARANCE[*]
HUMERUS, HEAD
3 wk		3 wk
CARPAL BONES
2 mo ± 2 mo	Capitate	2 mo ± 2 mo
3 mo ± 2 mo	Hamate	2 mo ± 2 mo
30 mo ± 16 mo	Triangular[†]	21 mo ± 14 mo
42 mo ± 19 mo	Lunate[†]	34 mo ± 13 mo
67 mo ± 19 mo	Trapezium[†]	47 mo ± 14 mo
69 mo ± 15 mo	Trapezoid[†]	49 mo ± 12 mo
66 mo ± 15 mo	Scaphoid[†]	51 mo ± 12 mo
No standards available	Pisiform[†]	No standards available
METACARPAL BONES
18 mo ± 5 mo	II	12 mo ± 3 mo
20 mo ± 5 mo	III	13 mo ± 3 mo
23 mo ± 6 mo	IV	15 mo ± 4 mo
26 mo ± 7 mo	V	16 mo ± 5 mo
32 mo ± 9 mo	I	18 mo ± 5 mo
FINGERS (EPIPHYSES)
16 mo ± 4 mo	Proximal phalanx, 3rd finger	10 mo ± 3 mo
16 mo ± 4 mo	Proximal phalanx, 2nd finger	11 mo ± 3 mo
17 mo ± 5 mo	Proximal phalanx, 4th finger	11 mo ± 3 mo
19 mo ± 7 mo	Distal phalanx, 1st finger	12 mo ± 4 mo
21 mo ± 5 mo	Proximal phalanx, 5th finger	14 mo ± 4 mo
24 mo ± 6 mo	Middle phalanx, 3rd finger	15 mo ± 5 mo
24 mo ± 6 mo	Middle phalanx, 4th finger	15 mo ± 5 mo
26 mo ± 6 mo	Middle phalanx, 2nd finger	16 mo ± 5 mo
28 mo ± 6 mo	Distal phalanx, 3rd finger	18 mo ± 4 mo
28 mo ± 6 mo	Distal phalanx, 4th finger	18 mo ± 5 mo
32 mo ± 7 mo	Proximal phalanx, 1st finger	20 mo ± 5 mo
37 mo ± 9 mo	Distal phalanx, 5th finger	23 mo ± 6 mo
37 mo ± 8 mo	Distal phalanx, 2nd finger	23 mo ± 6 mo
39 mo ± 10 mo	Middle phalanx, 5th finger	22 mo ± 7 mo
152 mo ± 18 mo	Sesamoid (adductor pollicis)	121 mo ± 13 mo
HIP AND KNEE
Usually present at birth	Femur, distal	Usually present at birth
Usually present at birth	Tibia, proximal	Usually present at birth
4 mo ± 2 mo	Femur, head	4 mo ± 2 mo
46 mo ± 11 mo	Patella	29 mo ± 7 mo
FOOT AND ANKLE[‡]
Values represent mean ± standard deviation, when applicable.

The norms present a composite of published data from the Fels Research Institute, Yellow Springs, OH (Pyle SI, Sontag L: Am J Roentgenol 1943; 49:102), and unpublished data from the Brush Foundation, Case Western Reserve University, Cleveland, OH, and the Harvard School of Public Health, Boston, MA. Compiled by Lieb, Buehl, and Pyle.

*	To nearest month.
†	Except for the capitate and hamate bones, the variability of carpal centers is too great to make them very useful clinically.
‡	Standards for the foot are available, but normal variation is wide, including some familial variants, so this area is of little clinical use.

 

 

COGNITIVE DEVELOPMENT.

The 6 mo old infant has discovered his hands and will soon learn to manipulate objects. At first, everything goes into the mouth. In time, novel objects are picked up, inspected, passed from hand to hand, banged, dropped, and then mouthed. Each action represents a nonverbal idea about what things are for (in Piagetian terms, a schema). The complexity of an infant’s play, how many different schemata are brought to bear, is a useful index of cognitive development at this age. The pleasure, persistence, and energy with which infants tackle these challenges suggest the existence of an intrinsic drive or mastery motivation. Mastery behavior occurs when infants feel secure; those with less secure attachments show limited experimentation and less competence.

A major milestone is the achievement at about 9 mo of object permanence (constancy), the understanding that objects continue to exist, even wheot seen. At 4–7 mo of age, infants look down for a yarn ball that has been dropped, but quickly give up if it is not seen. With object constancy, infants persist in searching, finding objects hidden under a cloth or behind the examiner’s back. Peek-a-boo brings unlimited pleasure as the child magically brings back the other player. Events seem to occur as a result of the child’s own activities.

EMOTIONAL DEVELOPMENT.

The advent of object permanence corresponds with qualitative changes in social and communicative development. Infants look back and forth between an approaching stranger and a parent, and may cling or cry anxiously, demonstrating “stranger anxiety.” Separations often become more difficult. Infants who have been sleeping through the night for months begin to awaken regularly and cry, as though remembering that the parents are in the next room.

A new demand for autonomy also emerges. Poor weight gain at this age often reflects a struggle between an infant’s emerging independence and parent’s control of the feeding situation. Use of the 2-spoon method of feeding (1 for the child and 1 for the parent), finger foods, and a high chair with a tray table can avert potential problems. Tantrums make their first appearance as the drives for autonomy and mastery come in conflict with parental controls and the infants’ still-limited abilities.

COMMUNICATION.

Infants at 7 mo of age are adept at nonverbal communication, expressing a range of emotions and responding to vocal tone and facial expressions. Around 9 mo of age, infants become aware that emotions can be shared between people; they show parents toys as a way of sharing their happy feelings. Between 8 and 10 mo of age, babbling takes on a new complexity, with many syllables (“ba-da-ma”) and inflections that mimic the native language. Infants now lose the ability to distinguish between vocal sounds that are undifferentiated in their native language. Social interaction (attentive adults taking turns vocalizing with the infant) profoundly influences the acquisition and production of new sounds. The first true word (i.e., a sound used consistently to refer to a specific object or person) appears in concert with an infant’s discovery of object permanence. Picture books now provide an ideal context for verbal language acquisition. With a familiar book as a shared focus of attention, a parent and child engage in repeated cycles of pointing and labeling, with elaboration and feedback by the parent.

IMPLICATIONS FOR PARENTS AND PEDIATRICIANS.

With the developmental reorganization that occurs around 9 mo of age, previously resolved issues of feeding and sleeping re-emerge. Pediatricians can prepare parents at the 6 mo visit so that these problems can be understood as the result of developmental progress and not regression. Parents should be encouraged to plan ahead for necessary, and inevitable, separations (e.g., baby sitter, daycare). Routine preparations may make these separations easier. Introduction of a “transitional object” may allow the infant to self-comfort in the parents’ absence.

Infants’ wariness of strangers often makes the 9 mo examination difficult, particularly if the infant is temperamentally prone to react negatively to unfamiliar situations. Initially, the pediatrician should avoid direct eye contact with the child. Time spent talking with the parent and introducing the child to a small, washable toy will be rewarded with more cooperation. The examination can be continued on the parent’s lap when feasible.

AGE 0–2 MONTHS

In this period, the infant experiences tremendous growth. Physiologic changes allow the establishment of effective feeding routines and a predictable sleep-wake cycle. The social interactions that occur as parents and infants accomplish these tasks lay the foundation for cognitive and emotional development.

PHYSICAL DEVELOPMENT.

A newborn’s weight may decrease 10% below birthweight in the 1st wk as a result of excretion of excess extravascular fluid and limited intake. Nutrition improves as colostrum is replaced by higher-fat breast milk, as infants learn to latch on and suck more efficiently, and as mothers become more comfortable with feeding techniques. Infants regain or exceed birth weight by 2 wk of age and should grow at approximately 30 g (1 oz)/day during the 1st mo (see Table 14-1 ). This is the period of fastest postnatal growth. Limb movements consist largely of uncontrolled writhing, with apparently purposeless opening and closing of the hands. Smiling occurs involuntarily. Eye gaze, head turning, and sucking are under better control and thus can be used to demonstrate infant perception and cognition. An infant’s preferential turning toward the mother’s voice is evidence of recognition memory.

Six behavioral states have been described (see Chapter 7 ). Initially, sleep and wakefulness are evenly distributed throughout the 24 hr day ( Fig. 8-1 ). Neurologic maturation accounts for the consolidation of sleep into blocks of 5 or 6 hr at night, with brief awake, feeding periods. Learning also occurs; infants whose parents are consistently more interactive and stimulating during the day learn to concentrate their sleeping during the night.

Figure 8-1  Typical sleep requirements in children.  (From Ferber R: Solve Your Child’s Sleep Problems. New York, Simon & Schuster, 1985.)

 

COGNITIVE DEVELOPMENT.

Caretaking activities provide visual, tactile, olfactory, and auditory stimuli; all of these support the development of cognition. Infants habituate to the familiar, attending less and less to repeated stimuli and increasing their attention when the stimulus changes. Infants can differentiate among patterns, colors, and consonants. They can recognize facial expressions (smiles) as similar, even when they appear on different faces. They also can match abstract properties of stimuli, such as contour, intensity, or temporal pattern, across sensory modalities. For example, infants at 2 mo of age can discriminate rhythmic patterns iative vs. non-native language. Infants appear to seek stimuli actively, as though satisfying an innate need to make sense of the world. These phenomena point to the integration of sensory inputs in the central nervous system.

EMOTIONAL DEVELOPMENT.

The infant is dependent on the environment to meet his or her needs. The consistent availability of a trusted adult to meet the infant’s urgent needs creates the conditions for secure attachment. Basic trust vs mistrust, the first of Erikson’s psychosocial stages, depends on attachment and reciprocal maternal bonding. Crying occurs in response to stimuli that may be obvious (a soiled diaper), but are often obscure. Infants who are consistently picked up and held in response to distress cry less at 1 yr and show less aggressive behavior at 2 yr. Cross-cultural studies show that in societies in which infants are carried close to the mother, babies cry less than in societies in which babies are only periodically carried. Crying normally peaks at about 6 wk of age, when healthy infants cry up to 3 hr/day, then decreases to 1 hr or less by 3 mo.

The emotional significance of any experience depends on both the individual child’s temperament and the parent’s responses (see Table 6-1 ). Consider the impact of different feeding schedules. Hunger generates increasing tension; as the urgency peaks, the infant cries, the parent offers the bottle or breast, and the tension dissipates. Infants fed “on demand” consistently experience this link between their distress, the arrival of the parent, and relief from hunger. Most infants fed on a fixed schedule quickly adapt their hunger cycle to the schedule. Those who cannot because they are temperamentally prone to irregular biologic rhythms experience periods of unrelieved hunger as well as unwanted feedings when they already feel full. Similarly, infants fed at the parents’ convenience, with neither attention to the infant’s hunger cues nor a fixed schedule, may not consistently experience feeding as the pleasurable reduction of tension. These infants often show increased irritability and physiologic instability (spitting, diarrhea, poor weight gain) as well as later behavioral problems.

IMPLICATIONS FOR PARENTS AND PEDIATRICIANS.

Success or failure in establishing feeding and sleep cycles determines parents’ feelings of efficacy. When things go well, the parents’ anxiety and ambivalence, as well as the exhaustion of the early weeks, decrease. Infant issues (colic) or familial conflict will prevent this from occurring. With physical recovery from delivery and endocrinologic normalization, the mild postpartum depression that affects many mothers passes. If the mother continues to feel sad, overwhelmed, and anxious, the possibility of moderate to severe postpartum depression, found in 10% of postpartum women, needs to be considered. Major depression that arises during pregnancy or in the postpartum period threatens the mother-child relationship and is a risk factor for later cognitive and behavioral problems. The pediatrician may be the first professional to encounter the depressed mother and should be instrumental in assisting her in seeking treatment (see Chapter 7 ).

AGE 2–6 MONTHS

At about 2 mo, the emergence of voluntary (social) smiles and increasing eye contact mark a change in the parent-child relationship, heightening the parents’ sense of being loved back. During the next months, an infant’s range of motor and social control and cognitive engagement increases dramatically. Mutual regulation takes the form of complex social interchanges, resulting in strong mutual attachment and enjoyment. Parents are less fatigued.

PHYSICAL DEVELOPMENT.

Between 3 and 4 mo of age, the rate of growth slows to approximately 20 g/day (see Table 14-1 and Figs. 9-1 and 9-2 ). By 4 mo, birth weight is doubled. Early reflexes that limited voluntary movement recede. Disappearance of the asymmetric tonic neck reflex means that infants can begin to examine objects in the midline and manipulate them with both hands (see Chapter 591 ). Waning of the early grasp reflex allows infants both to hold objects and to let them go voluntarily. A novel object may elicit purposeful, although inefficient, reaching. The quality of spontaneous movements also changes, from larger writhing to smaller, circular movements that have been described as “fidgety.” Abnormal or absent fidgety movements may constitute a risk factor for later neurologic abnormalities.

Increasing control of truncal flexion makes intentional rolling possible. Once infants can hold their heads steady while sitting, they can gaze across at things rather than merely looking up at them, and can begin taking food from a spoon. At the same time, maturation of the visual system allows greater depth perception.

In this period, infants achieve stable state regulation and regular sleep-wake cycles. Total sleep requirements are approximately 14–16 hr/24 hr, with about 9–10 hr concentrated at night and 2 naps/day. About 70% of infants sleep for a 6–8 hr stretch by age 6 mo (see Fig. 8-1 ). By 4–6 mo, the sleep electroencephalogram shows a mature pattern, with demarcation of rapid eye movement (REM) and 4 stages of non-REM sleep. The sleep cycle remains shorter than in adults (50–60 min vs approximately 90 min). As a result, infants arouse to light sleep or wake frequently during the night, setting the stage for behavioral sleep problems (see Chapter 18 ).

COGNITIVE DEVELOPMENT.

The overall effect of these developments is a qualitative change. At 4 mo of age, infants are described as “hatching” socially, becoming interested in a wider world. During feeding, infants no longer focus exclusively on the mother, but become distracted. In the mother’s arms, the infant may literally turn around, preferring to face outward.

Infants at this age also explore their own bodies, staring intently at their hands, vocalizing, blowing bubbles, and touching their ears, cheeks, and genitals. These explorations represent an early stage in the understanding of cause and effect as infants learn that voluntary muscle movements generate predictable tactile and visual sensations. They also have a role in the emergence of a sense of self, separate from the mother. This is the first stage of personality development. Infants come to associate certain sensations through frequent repetition. The proprioceptive feeling of holding up the hand and wiggling the fingers always accompanies the sight of the fingers moving. Such “self” sensations are consistently linked and reproducible at will. In contrast, sensations that are associated with “other” occur with less regularity and in varying combinations. The sound, smell, and feel of the mother sometimes appear promptly in response to crying, but sometimes do not. The satisfaction that the mother or another loving adult provides continues the process of attachment.

EMOTIONAL DEVELOPMENT AND COMMUNICATION.

Babies interact with increasing sophistication and range. The primary emotions of anger, joy, interest, fear, disgust, and surprise appear in appropriate contexts as distinct facial expressions. When face-to-face, the infant and a trusted adult match affective expressions (smiling or surprise) about 30% of the time. Initiating “games” (facial imitation, singing, hand games) increases social development. Such face-to-face behavior reveals the infant’s ability to share emotional states, the first step in the development of communication. Infants of depressed parents show a different pattern, spending less time in coordinated movement with their parents and making fewer efforts to re-engage. Rather than anger, they show sadness and a loss of energy when the parents continue to be unavailable.

IMPLICATIONS FOR PARENTS AND PEDIATRICIANS.

Motor and sensory maturation makes infants at 3–6 mo exciting and interactive. Some parents experience their 4 mo old child’s outward turning as a rejection, secretly fearing that their infants no longer love them. For most parents, however, this is a happy period. Most parents excitedly report that they can hold “conversations” with their infants, taking turns vocalizing and listening. Pediatricians share in the enjoyment, as the baby coos, makes eye contact, and moves rhythmically. If this visit does not feel joyful and relaxed, causes such as social stress, family dysfunction, parental mental illness, or problems in the infant-parent relationship should be considered. Parents can be reassured that responding to an infant’s emotional needs cannot “spoil” him or her. Giving vaccines and drawing blood while the child is seated on the parent’s lap increases pain tolerance.

AGE 6–12 MONTHS

With achievement of the sitting position, increased mobility, and new skills to explore the world around them, 6–12 mo old infants show advances in cognitive understanding and communicative competence, and there are new tensions around the themes of attachment and separation. Infants develop will and intentions, characteristics that most parents welcome, but still find challenging to manage.

PHYSICAL DEVELOPMENT.

Growth slows more (see Table 14-1 and Figs. 9-1 and 9-2 ). By the 1st birthday, birthweight has tripled, length has increased by 50%, and head circumference has increased by 10 cm. The ability to sit unsupported (6–7 mo) and to pivot while sitting (around 9–10 mo) provides increasing opportunities to manipulate several objects at a time and to experiment with novel combinations of objects. These explorations are aided by the emergence of a thumb-finger grasp (8–9 mo) and a neat pincer grasp by 12 mo. Many infants begin crawling and pulling to stand around 8 mo, followed by cruising. Some walk by 1 yr. Motor achievements correlate with increasing myelinization and cerebellar growth. These gross motor skills expand infants’ exploratory range and create new physical dangers as well as opportunities for learning. Tooth eruption occurs, usually starting with the mandibular central incisors ( Table 8-3 ). Tooth development reflects skeletal maturation and bone age, although there is wide individual variation ( Table 8-4 ).

TABLE 8-3   — Chronology of Human Dentition of Primary or Deciduous and Secondary or Permanent Teeth

	CALCIFICATION		AGE AT ERUPTION		AGE AT SHEDDING
	Begins At	Complete At	Maxillary	Mandibular	Maxillary	Mandibular
PRIMARY TEETH
Central incisors	5th fetal mo	18–24 mo	6–8 mo	5–7 mo	7–8 yr	6–7 yr
Lateral incisors	5th fetal mo	18–24 mo	8–11 mo	7–10 mo	8–9 yr	7–8 yr
Cuspids (canines)	6th fetal mo	30–36 mo	16–20 mo	16–20 mo	11–12 yr	9–11 yr
First molars	5th fetal mo	24–30 mo	10–16 mo	10–16 mo	10–12 yr	10–12 yr
Second molars	6th fetal mo	36 mo	20–30 mo	20–30 mo	10–12 yr	11–13 yr
SECONDARY TEETH
Central incisors	3–4 mo	9–10 yr	7–8 yr	6–7 yr
Lateral incisors	Max, 10–12 mo	10–11 yr	8–9 yr	7–8 yr
	Mand, 3–4 mo
Cuspids (canines)	4–5 mo	12–15 yr	11–12 yr	9–11 yr
First premolars (bicuspids)	18–21 mo	12–13 yr	10–11 yr	10–12 yr
Second premolars (bicuspids)	24–30 mo	12–14 yr	10–12 yr	11–13 yr
First molars	Birth	9–10 yr	6–7 yr	6–7 yr
Second molars	30–36 mo	14–16 yr	12–13 yr	12–13 yr
Third molars	Max, 7–9 yr	18–25 yr	17–22 yr	17–22 yr
	Mand, 8–10 yr

Adapted from chart prepared by P.K. Losch, Harvard School of Dental Medicine, who provided the data for this table. Mand, mandibular; Max, maxillary.

 

TABLE 8-4   — Time of Appearance in Roentgenograms of Centers of Ossification in Infancy and Childhood

BOYS—AGE AT APPEARANCE[*]	BONES AND EPIPHYSEAL CENTERS	GIRLS—AGE AT APPEARANCE[*]
HUMERUS, HEAD
3 wk		3 wk
CARPAL BONES
2 mo ± 2 mo	Capitate	2 mo ± 2 mo
3 mo ± 2 mo	Hamate	2 mo ± 2 mo
30 mo ± 16 mo	Triangular[†]	21 mo ± 14 mo
42 mo ± 19 mo	Lunate[†]	34 mo ± 13 mo
67 mo ± 19 mo	Trapezium[†]	47 mo ± 14 mo
69 mo ± 15 mo	Trapezoid[†]	49 mo ± 12 mo
66 mo ± 15 mo	Scaphoid[†]	51 mo ± 12 mo
No standards available	Pisiform[†]	No standards available
METACARPAL BONES
18 mo ± 5 mo	II	12 mo ± 3 mo
20 mo ± 5 mo	III	13 mo ± 3 mo
23 mo ± 6 mo	IV	15 mo ± 4 mo
26 mo ± 7 mo	V	16 mo ± 5 mo
32 mo ± 9 mo	I	18 mo ± 5 mo
FINGERS (EPIPHYSES)
16 mo ± 4 mo	Proximal phalanx, 3rd finger	10 mo ± 3 mo
16 mo ± 4 mo	Proximal phalanx, 2nd finger	11 mo ± 3 mo
17 mo ± 5 mo	Proximal phalanx, 4th finger	11 mo ± 3 mo
19 mo ± 7 mo	Distal phalanx, 1st finger	12 mo ± 4 mo
21 mo ± 5 mo	Proximal phalanx, 5th finger	14 mo ± 4 mo
24 mo ± 6 mo	Middle phalanx, 3rd finger	15 mo ± 5 mo
24 mo ± 6 mo	Middle phalanx, 4th finger	15 mo ± 5 mo
26 mo ± 6 mo	Middle phalanx, 2nd finger	16 mo ± 5 mo
28 mo ± 6 mo	Distal phalanx, 3rd finger	18 mo ± 4 mo
28 mo ± 6 mo	Distal phalanx, 4th finger	18 mo ± 5 mo
32 mo ± 7 mo	Proximal phalanx, 1st finger	20 mo ± 5 mo
37 mo ± 9 mo	Distal phalanx, 5th finger	23 mo ± 6 mo
37 mo ± 8 mo	Distal phalanx, 2nd finger	23 mo ± 6 mo
39 mo ± 10 mo	Middle phalanx, 5th finger	22 mo ± 7 mo
152 mo ± 18 mo	Sesamoid (adductor pollicis)	121 mo ± 13 mo
HIP AND KNEE
Usually present at birth	Femur, distal	Usually present at birth
Usually present at birth	Tibia, proximal	Usually present at birth
4 mo ± 2 mo	Femur, head	4 mo ± 2 mo
46 mo ± 11 mo	Patella	29 mo ± 7 mo
FOOT AND ANKLE[‡]
Values represent mean ± standard deviation, when applicable.

The norms present a composite of published data from the Fels Research Institute, Yellow Springs, OH (Pyle SI, Sontag L: Am J Roentgenol 1943; 49:102), and unpublished data from the Brush Foundation, Case Western Reserve University, Cleveland, OH, and the Harvard School of Public Health, Boston, MA. Compiled by Lieb, Buehl, and Pyle.

*	To nearest month.
†	Except for the capitate and hamate bones, the variability of carpal centers is too great to make them very useful clinically.
‡	Standards for the foot are available, but normal variation is wide, including some familial variants, so this area is of little clinical use.

 

 

Assessment and care of newborn, infant and toddler.

Breastfeeding and weaning. Toilet training.

Safety promotion. Routine health screenings.

 

OBJECTIVES

Theoretical Approaches to the Growth and Development of Children

 

Growth and Development of the Newborn

 

Growth and Development of the Infant

 

Growth and Development of the Toddler

 

Theoretical Approaches to the Growth and Development of Children

Understanding human development is an essential part of the nursing process.

Knowledge of normal behavior for specific age groups allows for individualizing assessments and care plans. Emphasis on promoting and maintaining health, anticipatory guidance related to human development, and assisting children and families to achieve optimal development are all important aspects of pediatric nursing. Knowledge of several principles, issues, and theories help us to understand holistic optimal development and care. This chapter will describe the various principles and issues that are interwoven within the major developmental theories discussed. Each theoiy will be fully explained and analyzed. The discussion will also include ideas on how the nurse can apply the theories to practice.

GROWTH, MATURATION, AND DEVELOPMENT

Growth, maturation, and development are common terms used to describe human development. An explanation of these terms and of the age ranges associated with child development is needed before principles, issues, and theories can be understood. Growth refers to a physiologic increase in size through cell multiplication or differentiation. This is most obviously seen in weight and height changes occurring during the first year of life. Maturation refers to changes that are due to genetic inheritance rather than life experiences, illness, or injury.

These changes allow children to function at increasingly higher and more sophisticated levels as they get older. Development refers to the physiological, psychosocial, and cognitive changes occurring over one’s life span due to growth, maturation, and learning, and assumes that orderly and specific situations lead to new activities and behavior patterns (Figure 1).

Figure 1 (A) Toddlers are developing their gross motor skills. (B) School-aged children often become involved in physical activities and team sports.

 

The five stages and age ranges of human development relating specifically to pediatric nursing are found in Table 1.

Table 1. Stages, Age Ranges, and Characteristics of Human Development

Related to Pediatric Nursing

Principles of Growth and Development

At least eight principles providing a framework for studying human development are embedded within the issues and theories discussed in the following pages. Although not all of these principles are proven by research, they are often observed in children and generally assumed to be true (Hetherington & Parke, 1993; Murray & Zentner, 2001).

1. Development is orderly and sequential. This principle suggests that maturation follows a predictable and universal timetable. For example, children learn to crawl before they learn to walk, and they learn to walk before they learn to run. These changes occur rapidly during the first year of life and slow during middle and late childhood. Even though the onset and length of each developmental change vary among children, the basic sequence is the same, allowing comparison to norms.

2. Development is directional. Skill development proceeds along two different pathways: cephalocaudal and proximodistal. Cephalocaudal development proceeds from the head downward. Therefore, areas closest to the brain or head develop first, followed by the trunk, then legs and feet. For example, head control is followed by sitting, then crawling, and then walking. Proximodistal development proceeds from the inside out. Controlled movements closest to the body’s center (trunk, arms) develop before controlled movements distant to the body (fingers). For example, grasping changes from using the entire hand to just the fingers as infants get older.

3. Development is unique for each child. Ever)’ child has a unique timetable for physiological, psychosocial, cognitive, and moral development. For example, some children can name four colors by the time the y are 3 years old, whereas others cannot name four colors until they are 4V2 years old. Some children walk well at 11 months; others do not walk well until they are 14 months old.

4. Development is interrelated. Physiological, psychosocial, cognitive, and moral aspects of development affect and are affected by one another. For example, central nervous system maturation is necessary for cognitive development. Children cannot be independent in toileting if they are not aware of the urge to void and cannot independently remove clothing.

5. Development becomes increasingly differentiated. This means responses become more specific and skillful as the child grows. Young infants respond to stimuli in a generalized way involving the entire body, whereas older children respond to specific stimuli in a more refined and specialized way. For example, infants will react with their entire body to pain by crying and withdrawing, whereas a child is able to localize the pain, can often identify its source, and may only withdraw the extremity experiencing the pain. An infant will use the entire hand to grab a toy before developing the fine motor ability necessary for the pincer grasp.

6. Development becomes increasingly integrated and complex. This means, as new skills are gained, more complex tasks are learned. For example, learning to drink from a cup initially requires eye-hand coordination, then grasping, and then hand-mouth coordination. Infants’ cooing is followed by babbling, before these sounds are refined into the understandable speech of a child.

7. Children are competent. They possess qualities and abilities ensuring their survival and promoting their development. For example, newborns can cough, sneeze, suck, swallow, digest, breathe, and elicit caretaking responses from adults. Children make their needs known to caregivers in increasingly sophisticated ways so that others know if they are cold, hungry, or in pain.

8. New skills predominate. This occurs because of the strong drive to practice and perfect new abilities, especially early in life, when the child is not capable of coping well with several new skills simultaneously. For example, when children are learning to walk, talk, or feed themselves with utensils, their attention and effort is focused on developing that one skill; they do not usually learn to walk, talk, and feed themselves at the same time.

Issues of Human Development

Theories on growth and development are often considered from the perspective of seven issues. These issues help explain how development occurs and what humans are like and can be applied to theories of human development. These issues answer questions related to the importance of biology or the environment on development, whether children are inherently good, bad, or actively involved in their own development, if development occurs gradually or abruptly, if children are more similar than different from one another, or if one’s personality or way of interacting with others remains stable throughout life. The issues discussed include nature versus nurture, continuity versus discontinuity, passivity versus activity, critical versus sensitive periods, universality versus context specificity, assumptions about humaature, and behavioral consistency.

Nature versus Nurture

One of the more important and oldest issues discussed in human development is the nature/nurture controversy. This debate concerns the influence that biology (nature) and the environment (nurture) have on an individual. Nature describes genetically inherited traits such as eye color or body type, or disease such as cystic fibrosis or hemophilia. This view sees development as predetermined by genetic factors and not altered by the environment. A person believing in the principle of nature would suggest that all normal children achieve identical developmental milestones at a similar time due to maturational forces. If children differed in achieving these milestones, it would be because of differences in their genetic makeup. Nurture refers to the influences that the environment has on development, and includes the influences that child-rearing methods, culture, learning experiences, and society have on development. A person believing in the principle of nurture would suggest that development can take different paths depending on the experiences that an individual has over a lifetime.

Today, most developmentalists believe that both nature and nurture are important, and that the relative contribution of each depends on the aspect of development studied. Developmentalists today are also more concerned about how biological and environmental factors interact to produce developmental differences and changes, rather than the importance of one over the other .

Continuity versus Discontinuity

This issue addresses the nature of change across development. Continuity suggests that change is orderly and built upon earlier experiences. Development is a gradual and smooth process without abrupt shifts; the course of development looks like a smooth growth curve. This issue also suggests early and late development are connected; aggressive toddlers become aggressive adults, curious infants become creative adolescents, and shy preschoolers become introverted adults. Finally, continuity proposes that changes occur quantitatively, or in degrees. For example, when children grow older, they become taller, run faster, and learn more about the world around them.

Discontinuity suggests development is a series of discrete steps or stages that elevate the child to a more advanced or higher level of functioning with increased age. The course of development looks like a flight of stairs. There is no connection between early and later development; behavior seen later in life has replaced behavior seen earlier in life. For example, infants once comfortable around strangers may come to fear them as they get older; a shy and introverted preschooler may become an outgoing, extroverted adolescent. Discontinuity would also argue that adult behavior cannot be predicted by knowing what the person was like as a child. Finally, discontinuity implies qualitative change, or changes that make the individual different as growth occurs, as when a nonverbal infant becomes a toddler using language, or when a prepubertal child becomes a mature adolescent.

Passivity versus Activity

This issue views the child as either a passive recipient shaped by external environmental forces, or as internally driven and actively participating in development. The passive view suggests that child-rearing beliefs, practices, and behaviors cause children to be either shy or assertive. Children become delinquent because of their association with an antisocial peer group. Talented and creative teachers deserve credit for a child’s interest in mathematics or literature. Those disagreeing with this view believe children purposefully, creatively, and actively seek experiences to control, direct, and shape their development. Active children also modify caregiver, peer, and teacher behavior (Figure 2).

Figure 2 Active children are interested in learning about other children’s projects and art work.

 

For example, an inquisitive, friendly child may encourage that same behavior in an otherwise indifferent or unfriendly peer or adult.

Critical versus Sensitive Period

This issue concerns the importance of different time periods in development, and asks if some phases are more important than others in developing particular abilities, knowledge, or skills. The critical period refers to a limited time span when a child is biologically prepared to acquire certain behaviors, but needs the support of a suitably stimulating environment. Indeed, there are some periods during development when childreeed to experience certain sensory and social input if their development is to proceed normally. The first 3 years of life are important for developing language, social, and emotional responsiveness. If there is little or no opportunity for these experiences during this time, children may have difficulty learning language, developing close friendships, or having an intimate emotional relationship later in life.

The sensitive period, on the other hand, is a time span that is optimal for certain capacities to emerge when the individual is especially receptive to environmental influences (Bornstein, 1989). Supporters of this view believe some behaviors can be modified during early development. For example, infants reared in an impoverished orphanage grew up without identifiable intellectual deficits if they were placed in a stimulating and nurturing adoptive home (Skeels, 1966). The fact that early experiences can be modified suggests humans are malleable and adaptable and, for some areas of development, there are sensitive rather than critical periods.

Universality versus Context Specificity

The importance of culture to development is embedded within this issue. Some theorists believe an individual’s culture has a profound influence on development. Others suggest there are culture-free laws of development that apply to all children in all cultures. For example, universality would say humans follow similar developmental pathways regardless of their culture: language is acquired and used at 11-14 months of age, cognitive changes preparing children for school or higher learning occur during 5-7 years of age, and sexual maturity is reached during the preteen or teenage years. Context specificity on the other hand, would suggest there are differences in children related to cultural values, beliefs, and experiences. For example, some societies encourage early walking by providing opportunities to exercise and practice these new skills, whereas in other societies carrying or swaddling infants is the norm, thereby reducing the chance of walking until older.

Assumptions about Human Nature

The doctrine of original sin used by Thomas Hobbes (1588-1679) to describe a child’s nature, suggests children are inherently evil and selfish egotists who must be controlled by society. The doctrine of innate purity, proposed by Jean Jaques Rousseau (1712-1778), suggests children are inherently good and born without an intuitive sense of what is right and wrong. The doctrine of tabula rasa, proposed by John Locke (1632-1704), suggests children are neither good nor evil, but rather enter the world as a blank slate without inborn tendencies, and are molded through life experiences. These assumptions are based on 17th and 18th century social philosophers and rarely addressed directly in theories of human development today. However, emphasis on positive or negative aspects of a child’s character and a particular theorist’s belief reflect an individual’s orientation and assumptions about humaature. For example, if one believes children are inherently caring and helpful, or on the other hand, innately selfish, child-rearing practices would vary. Permissive parents may believe children should be allowed to develop without interference (innate purity), whereas authoritarian parents may take an approach that would combat and control their child’s selfish and aggressive impulses so they would develop positive behaviors.

Behavioral Consistency

This issue addresses whether or not a child’s basic behavioral traits change according to the setting (school, neighborhood, family). Some theorists suggest individual personality characteristics and predispositions cause children to behave similarly no matter the setting. Others suggest children’s behavior changes from one setting to another. Those supporting the former view would say a particular child can always be described as honest, helpful, aggressive, or independent, no matter the situation. The latter view would argue children’s behavior shifts according to the situation and who/what is present—friend ieed, angry caregiver or teacher, competitive game, or a difficult test.

 

THEORIES OF HUMAN DEVELOPMENT

The following theoretical views present various ways of examining human development during childhood and adolescence (Figure 3).

Figure 3. The Eclectic Nature of Human Development

Freud and Psychosexual Development

Sigmond Freud (1856-1939), a Viennese physician, originated the psychosexual theory emphasizing the importance of unconscious motivation and early childhood experiences in influencing behavior, and describing concepts related to personality and stages of development (Freud, 1933). His ideas, considered radical when proposed early in the twentieth century, became popular in the United States during the 1930s and continue to influence thinking about human development today.

Central to Freudian theory is the notion that two basic biological instincts (life and death) motivate behavior, must be satisfied, and compete for supremacy (Freud, 1933). The life instinct aims for survival and is responsible for such life sustaining activities as eating, breathing, copulation, and behavior that expresses self preservation, love, and constructive conduct. The death instinct on the other hand, is a destructive force expressed by self centered and cruel behavior, hate, aggression, and destructive conduct. These instincts, the source of psychic energy that drives human behavior, have three components: id, ego, and superego. As the child matures, these components of personality become more rational and reality bound (Freud, 1933).

During infancy, all psychic energy resides in the id, the inborn element of personality that is driven by selfish urges. The id obeys the “pleasure principle,” oriented toward maximizing pleasure and immediately satisfying needs, even when biologic needs cannot be appropriately or realistically met. The id is manifest as the irrational, selfish, impulsive part of personality (Freud, 1933).

As the infant develops, the ego or rational and controlling part of the personality emerges. The ego operates according to the “reality principle” as realistic ways of gratifying instinctual drives are discovered. Ego functions allow individuals to be successful and include memory, cognition, intelligence, problem solving, compromising, separating reality from fantasy, and incorporating experiences and learning into future behavior. Ego development continues during childhood and throughout the life span (Freud, 1933).

The third component of personality is the superego or conscience, which emerges when the child internalizes caregiver or societal values, roles, and morals. Superego development begins in infancy, and becomes apparent in the preschool and school-aged years when the child learns socially acceptable behavior. The superego strives for perfection rather than for pleasure or reality. After the superego emerges, children have a conscience that tells them the difference between right and wrong, and which behaviors are socially acceptable outlets for the id’s undesirable impulses. The superego also serves as a disciplinarian by creating feelings of remorse and guilt for transgressing rules, and self praise and pride for adhering to rules (Freud, 1933).

Conflict among the id, ego, and superego is inevitable throughout life. Mature, healthy personalities, however, are in a dynamic balance, with the id communicating its basic needs, the ego restraining the id until realistic ways are found to satisfy these needs, and the superego determining whether or not the ego’s problem-solving strategies are morally acceptable. Freud believed defense mechanisms, such as regression, displacement, projection, and sublimation were created as escape valves to repress painful experiences or threatening thoughts coming from the id’s unsatisfied needs that were not managed by the ego or superego (Freud, 1933).

To Freud, the most important life instinct was the sex instinct, which changed its character and focus according to biological maturation. (Freud’s concept of sex and sexuality was broader than what is implied in the use of these words today, and indicates sexuality in its genital manifestations as well as any kind of pleasure seeking.) As the sex instinct’s psychic energy (libido) shifts from one part of the body to another, the child passes through five stages of development: oral, anal, phallic, latency, and genital (Table 2). Each stage is related to a specific body part (erogenous zone) that brings primary pleasure to the child during that stage. According to Freud, adult personality is profoundly impacted by how each stage is managed.

Table 2. Stages of Freud’s Psychosexual Development

Application

Freud provides insight into human actions, and helps us understand others by realizing all behavior is meaningful and may hide inner needs or conflicts. Therefore, it is especially important to teach this information as well as normal behavior for the various stages to parents. Since during infancy comfort and pleasure are obtained through the mouth, it is important to offer babies a pacifier if they are NPO, or a bottle, pacifiers, or the breast after painful procedures. When hungry, they should be promptly fed (if not NPO). Providing plastic or rubber rings or other toys suitable for teething infants are also appropriate.

Toddlers are gratified by controlling body excretions. Therefore, when caring for children between 1 and 3 years of age, asking about the status of toileting and words and rituals used for elimination is important. It is wise to provide a child-sized potty chair and avoid starting toilet training during periods of illness or stress. In addition, toddlers should be reprimanded carefully if toilet training is difficult or if the child has accidents. Finally, parents need to be flexible and patient in toilet training and begin when the toddler indicates readiness.

Preschool children are concerned about sexuality and initially identify with the parent of the opposite gender. Nurses should teach parents that curiosity about gender differences and masturbation is normal. In addition, nurses should be aware of preschoolers who appear more comfortable with a particular nurse (no matter the gender), attempt to accommodate that situation, and encourage parents to participate in the care of their child. School-aged children and adolescents should be encouraged to have contact with friends, and their questions answered honestly. Privacy for both school age and adolescent clients should be ensured during physical examinations or when they are changing clothes or showering in gym class.

Erikson and Psychosocial Development

Erik Erikson (1902-1994) acknowledged the contribution of biologic factors to development, but felt that the environment, culture, and society were also important. His psychosocial (epigenetic) theory of development stresses the complexity of interrelationships existing between emotional and physical variables during one’s lifetime (Erikson, 1963).

Erikson agreed with many of Freud’s ideas regarding basic instincts and the three components of personality (id, ego, superego). In addition, he believed development was stagelike, and conflict resolution was necessary at each stage in order for the individual to successfully advance to the next stage. In fact, Erikson’s first five stages of development and the approximate ages of each stage correspond closely with those outlined by Freud (Table 3). Erikson differs from Freud, however, in that he believes children actively adapt and explore their environment instead of being passively controlled and molded by caregivers and society. Erikson also assumes humans are rational creatures whose actions, feelings, and thoughts are controlled primarily by the ego instead of the id, superego, or conflicts between the three components of personality.

Table 3. Comparison of Stage Theories of Human Development

For Erikson, lifespan development consisted of eight sequential stages. Five of these stages describe infants through adolescents (Table 4). Each stage is dominated by major developmental conflicts or crises related to societal demands and expectations that must be addressed or resolved before the individual can progress to the next stage.

Table 4. Stages of Erikson’s Psychosocial Theory of Development

The resolution of each conflict or crisis might be positive (favorable and growth enhancing), or negative (unfavorable, frustrating, and making later development difficult). Erikson believed major conflicts occurring during each stage are rarely completely resolved. Instead, they are of primary or dominant importance during a particular stage and then become less important or dominant as other conflicts arise in later stages. In addition, he suggests conflict is rarely completely resolved positively. Rather, the positive resolution predominates over the negative resolution during a particular stage. Failure to successfully master a crisis or developmental task does not destine the child to failure since delayed mastery is possible. It is true, however, that difficulty at one stage may affect progress through later stages (Erickson, 1963).

Application

Erikson’s theory provides us with a means of assessing and gaining insight into five developmental crises children and adolescents face, and allows us to use this knowledge to teach caregivers behaviors they can expect to see in their children. It also helps us realize the importance of societal influences on health and behavior, and that psychosocial development is a lifelong process. Erikson’s theory is easy to apply to practice. Health care provides a variety of situations and opportunities where a child’s progression through stages can be facilitated, and caregivers taught how to encourage positive resolution of each developmental crisis. Since meeting basic needs (feeding, bathing, changing) in a timely and appropriate fashion during infancy results in the development of trust, it is critical that feeding and hygiene needs be met promptly. When an infant is ill, parents should be encouraged to spend as much time as possible with their infant.

Figure 4. Letting toddlers feed themselves is important.

For toddlers, independence is increasing and self control gained by maintaining familiar daily routines. Allowing opportunities for the child to independently dress, feed, and do self-hygiene care is important (Figure 4). If restraint  for procedures or treatments is necessary, explanations and comfort should be provided and caregivers encouraged to participate. Love, approval, and praise are important for toddlers and children in all stages.

Preschoolers like to initiate activities and remain curious and interested in the world around them. Opportunities to explore, ask questions, and create should be provided. Nurses should accept children’s choices and negative expression of feelings, answer their questions, and allow them to play with medical equipment so their curiosity is satisfied and their knowledge about experiences broadened.

For school-aged children, involvement and success in a variety of activities provide a sense of self-worth and value. Nurses should provide the school-aged child with opportunities for continuing school work if hospitalized or ill, maintaining hobbies or activities, interacting with their peers, and adjusting to limitations imposed by illness or hospitalization.

Primary care nurses need to be in touch with school nurses when a child with a chronic condition is hospitalized and when this child is ready to return home and to school.

Adolescents are searching for who they will become independent from their parents. Nurses should allow adolescent clients to be as autonomous as possible, encourage them to take responsibility for their own actions, support their life choices, introduce them to other teens, and provide them with a separate recreation or activity area if in an acute care setting. Parental involvement in the care of adolescents is still important.

Sullivan and Interpersonal Development

Harry Stack Sullivan (1892-1949) focused on interpersonal relations as important behavioral motivators and the source of psychological health. His interpersonal theory posits that the self concept is the key to personality development.

He acknowledged the importance of the environment (especially the home), and also emphasized the role of social approval and disapproval in forming a child’s self concept. Sullivan believed personality development was largely the result of childhood experiences, interpersonal encounters, and the mother-child relationship. How well physiological needs were met in an interpersonal situation affected not only one’s sense of satisfaction and security, but also allowed anxiety to be avoided. Poor environmental interactions caused anxiety and tension; a positive social relationship resulted in security, a major life goal (Sullivan, 1953).

Stages of Interpersonal Development

Sullivan describes seven stages of interpersonal development (Sullivan, 1953); six relate specifically to infants through adolescents (Table 5). Sullivan believed each stage prepared the personality for the next stage and failure to successfully achieve stage activities limited personality development and opportunities for a successful life. Refer to Table 3 for a comparison of Sullivan’s first six stages with Freud’s and Erikson’s stages.

Table 5. Stages of Sullivan’s Interpersonal Theory of Development

Application

Sullivan also has relevance to the nursing care of children. Perhaps the two most important points he made is to emphasize the significance of interpersonal relations with others on personality development, and meeting the child’s basic needs in a timely and appropriate fashion. This does not mean, however, that caregivers protect children from all discomforts or meet needs before they are expressed. The key is to relieve unpleasant feelings associated with basic needs so feelings of security and attachment result in a “good me” rather than a “bad me.” Sullivan also has helped us realize the important place chums have in a school-aged child’s life, and how this experience is critical for developing interpersonal relationships later in life.

 

Behavioral Perspective

The behavioral perspective posits that human actions and interactions come from learned responses to environmental stimuli. Behavioral theorists study human behavior in a laboratory setting and then apply this information to the general population, and look for ways to alter or control the environment to change, modify, or teach desired behaviors.

Pavlov and Classical Conditioning

Ivan Pavlov (1849-1936), a Russian physiologist, initially discovered linkages between a stimulus and a response while studying a dogs response to food. He learned a dog would respond (salivate) not only when he saw food (unconditioned stimulus), but also when he saw the person who fed him or heard a bell ring just before the food appeared (conditioned stimulus), because the dog had learned that the bell or appearance of the man meant food would follow. This learning to respond to a new stimulus the same way a familiar stimulus was responded to is called classical conditioning, and suggests learning occurs when a response that is already part of the organism s normal activities (salivating) can be reproduced by an associated stimulus that previously would not have produced it—for example, the presence of a person or the sound of a bell (Crain, 2000; Murray & Zentner, 2001). Another example of classical conditioning would be when an infant, seeing the spoon used for feeding, becomes excited (waving hands and arms, kicking legs, making babbling sounds) because the spoon is associated with being fed and the infant knows that feeding time is coming soon.

Skinner and Operant Conditioning

Operant conditioning, a term originated by B. F. Skinner (1904-1990), involves behavioral changes due to either negative (punishment) or positive (reinforcers) consequences rather than just the occurrence of a stimuli. If behavior is rewarded, the likelihood of it reoccurring increases; if behavior is punished, chances are it will not reoccur. Positive reinforcement includes friendly smiles, praise, or special treats/privileges; punishment includes criticism, a frown, or withdrawal of privileges. Skinner discovered behavioral change became more permanent when consequences were provided intermittently rather than continuously, and believed the essence of development involved constantly acquiring new behaviors or habits due to reinforcing or punishing stimuli. He emphasized why behaviors occur rather than simply describing the behavior seen (Skinner, 1953).

Bandura and Social Learning

A third kind of behaviorism is social learning, proposed by Albert Bandura (b. 1925). According to this view, children learn by imitating and observing others (a model), as well as by classical and operant conditioning. Social learning theorists also believe behavior is influenced by the environment and learned through various experiences. However, they do not believe behavioral change is a mindless response to stimuli. Rather, they suggest personality, past experiences, relationships with the model, the situation itself, and cognition also impact behavioral change (Bandura, 1977). Cognition plays a part because to successfully imitate behavior, a child must be capable of remembering, rehearsing, and organizing the behavior seen. Children often will think about connections between behavior and consequences and will likely be affected more by what they believe will be the consequences rather than what the consequences actually are. For example, learning to play a musical instrument is expensive for families, and demanding and time consuming for children. However, children and their parents continually tolerate the cost and inconvenience because they are anticipating rewards once the child learns to play the instrument.

Bandura also believes modeled behavior can be weakened or strengthened depending on whether it is punished or rewarded. Bandura suggests observational learning (learning that results from merely watching others), where children acquire a variety of new behaviors when “models” are merely pursuing their own interests and not attempting to teach, reward, or punish, is another important method of learning behaviors. For example, research has shown children who watch television violence frequently are more aggressive than those children who do not watch very much television violence (Murray & Zentner, 2001). Finally, Bandura found children tend to model behavior of children and adults of their same gender more often thaot, and males model behavior of others more often than females do.

Application

Although behaviorism has been criticized for denying the inherent capabilities of persons to willfully respond to environmental situations and its relative elementary nature, it is useful in health care. Positive behaviors can be reinforced by encouragement, praise, and other rewards, and behaviors needing to be altered or removed from a child’s repertoire can be extinguished by either ignoring or punishing. Parents commonly use these concepts when toilet training or teaching their children cooperation, compromise, helpfulness, and empathy. Some academic and preschool programs and parents use behavior modification and time-out activities to modify and change undesirable behavior in children. Operant conditioning can also help plaew or extinguish undesirable behavior by providing specific guidelines, determining available reinforcers, identifying responses acceptable for reinforcement, and planning how reinforcers will be scheduled so behavior is repeated.

Social learning theory is also readily applicable to health care. Children often will cooperate with procedures (blood draws, X rays) if they see other children or adults they emulate cooperating for the same procedure. Nurses can help parents realize that their appearance and behavior is often imitated by their children, and determine who might be significant role models for their children to emulate. Finally, nurses need to demonstrate nurturing approaches or discipline methods so parents learn effective parenting practices.

 

Assessment and care of toddler. Toilet Training.

Safety promotion. Routine health Screenings.

Objectives:

1.     #PHYSIOLOGICAL DEVELOPMENT

2.     #PSYCHOSEXUAL DEVELOPMENT

3.     #PSYCHOSOCIAL DEVELOPMENT

4.     #COGNITIVE DEVELOPMENT

5.     #HEALTH PROMOTION

6.     #ROUTINE HEALTH SCREENINGS

7.     #TOILET TRAINING

Toddlerhood is a difficult, exciting, and interesting period of life. Fundamental learning processes develop as the child begins to seek autonomy, explores the world, learns how things work, begins to tolerate limitations, expresses desires, and develops relationships. However, the toddler s excitement and frustration make this a period of incredible challenge for caregivers and health care providers alike.

Toddlerhood is the magical time of childhood encompassing the tumultuous twos and the terrific threes. This 24-month-span (12-36 months of age) reflects periods of rapid, unprecedented maturation, and change in the life of the child and family. The toddler evolves from a dependent infant with limited mobility and communication skills, into a more independent, very mobile, verbal, and inquisitive member of the family.

Promoting toddler health and maintaining wellness involves knowledge of normal growth and developmental processes, an understanding of common significant milestones, and the ability to anticipate deviations that may occur within the individual child. Knowledge of concepts and theories that support toddler development is very important.

As the toddler develops autonomy and a sense of identity, increased motor skills combined with a lack of experience and judgment can present innumerable dangers. Nurses and caregivers, therefore, need to utilize strategies to promote and assist the toddlers mastery of major developmental skills, while at the same time protecting the child from environmental dangers, provide structured guidelines and loving discipline (needed, but seldom desired), and promote a sense of independence and inquisitiveness (Figure 9-1).

Toddler physiological, psychosexual, psychosocial, cognitive, and moral development will be discussed in the following pages. It is always important to remember, however, that development in each area significantly impacts overall growth, development, and maturation, and no area of development can be viewed in isolation. Information about issues commonly arising during the toddler stage will also be presented.

Figure 9-1 Toddlers are usually happy and love to be around others.

PHYSIOLOGICAL DEVELOPMENT

The physical changes of toddlerhood occur in a fairly predictable manner; however, no child can be held to a rigid time frame of when those milestones will be reached. While some children initially direct their energy toward accomplishing motor activities first, others initially concentrate on verbal mastery. Generally, this does not mean one toddler is advanced and another delayed, but rather it means both will accomplish desired developmental tasks within a normal range of time, but at their own pace. It is important to provide caregivers with information to help them understand and anticipate developmental sequences. It is essential, however, that they also realize the information provides flexible guidelines rather than hard and fast rules.

Physical growth, so rapid in infancy, slows during toddlerhood, but the toddler should show a steady increase in growth, with an average weight gain of about 5 pounds per year and an increase in height averaging 3 inches per year. This slowed growth rate is evidenced by the toddlers decline in appetite and erratic eating habits. Physical appearance also changes markedly. The head gains a more proportional dimension to the rest of the body, reflecting slower brain growth, as the extremities lengthen. Chest circumference increases and soon exceeds the abdominal girth, and the topheavy, wide base (feet spread) pot-bellied stance and toddling gait of young toddlers eventually gives way to a well-balanced appearance and gait as bones lengthen and strengthen, and abdominal muscle replaces adipose tissue. Children learn to walk at various ages, with some beginning as early as 12 months; however, most toddlers are walking by 15 months and climbing stairs by 18 months—and spending a great deal of time perfecting their efforts, compelled to repeat the process over and over again until the skill is mastered (Figure 9-2).

Figure 9-2 A sense of balance and coordination develops as the toddler grows and

gains more control over her body.

 

Neurological System

The toddler engages in many behaviors reflecting central and peripheral nervous system maturation. Brain growth continues slowly, corresponding to advancing intellectual skills and fine motor development. Improved coordination and equilibrium parallels the almost complete (by 2 years) myelinization of the spinal cord as evidenced by the toddler’s refined skill in walking, jumping, and climbing. Increasing eye-hand coordination, manual dexterity, and walking/running skills contribute significantly to the toddler’s locomotion and socialization. These skills promote throwing and retrieving a variety of objects, opening and closing containers with lids, and building objects with blocks before knocking them down (Gemelli, 1996). The neurophysiologic changes that have the greatest impact upon family/child education and suggested nursing interventions are listed in Table 9-1.

Musculoskeletal System

Increased bone length, muscle maturation, and increased muscle strength enable toddlers to develop autonomy. Major advances occurring in the musculoskeletal system during toddlerhood are reflected in Table 9-2. See also Toddler Week by Week

Gastrointestinal/Genitourinary System

The gastrointestinal/genitourinary system continues to mature during these years. The stomach enlarges in size, allowing consumption of the traditional three meals per day, all deciduous teeth generally erupt by 30 months of age, and improved eye-hand coordination enables self-feeding. This would seem to set the perfect scenario for a toddler growth spurt, however, this does not generally occur. Instead, the toddler enjoys a gradual increase in size, accompanied by a decreased appetite and a ritualistic interest in limited types of food. Toddlers also vary in their energy requirements, eating large amounts of food one day and very little food the next. The food likes and dislikes also differ from day to day. This period of decreased appetite as a result of decreased caloric need is often referred to as a time of physiologic anorexia.

Even though caloric needs diminish during this time, protein requirements, though less, remain higher than for other age groups. Vitamin and mineral requirements—particularly calcium, phosphorous, and iron (essential for bone and muscle growth)—increase slightly. This can create concern since toddlers often go through food fads and have a decreased food intake. Measures should be taken to help reduce the amount of fat in the toddlers diet by providing low-fat or skim milk, lean meats, and low-fat products (cheese). Bladder and bowel control is typically achieved during this time period, and children are able to retain urine up to 4 hours before needing to void. Specific gastrointestinal and genitourinary changes that can be expected and accompanying nursing interventions can be found in Table 9-3.

Cardiorespiratory System

During toddlerhood, the cardiorespiratory system continues to mature; vital signs become more stable and move closer to adult norms. Respiratory and cardiac rates slow, while blood pressure rises. Other significant factors related to cardiopulmonary assessment can be found in Table 9-4.

 

Sensory System

In addition to the physiologic changes noted in Tables 9-1 to 9-4, the senses of hearing, smell, taste, touch, and vision develop and begin to connect, since toddlers utilize all five senses to explore the world and exert autonomy and independence. Caregivers and health care providers need to be aware of behaviors reflecting hearing and vision difficulties such as failure to develop language, unusual responses to loud sounds, or increased falls. Baseline hearing and vision screening should be performed during toddlerhood and appropriate strategies, if necessary, immediately begun. Refer to Chapter 31 for more information. Toddler vision should be 20/20 to 20/40, with full binocular capabilities reached shortly after 12 months of age. Depth perception continues to develop throughout the toddler years. Developing depth perception, combined with inquisitiveness, poor judgment, and occasional lack of coordination, puts the toddler at risk for frequent falls when learning to walk, run, and climb stairs.

 

PSYCHOSEXUAL DEVELOPMENT

Attitudes related to gender identity, sex roles, and sexuality are mostly determined by the values and morals of the caregiver and the environment. Toddlers are generally able to recognize gender differences by 2 years of age and begin to explore and recognize body parts, most often during toilet training. According to Freud (1957), toddlers are in the anal stage of development. (Refer to Chapter 6 for more information on Freud.) Freud also first pointed out the tension revolving around toddler bowel/bladder training, and viewed toilet training as a possible way of resolving conflict and handling stress. He believed improperly managed toilet training could lead to life-long psychological trauma with accompanying physical bowel/bladder responses (Freud, 1957).

Many thoughts and activities of both the caregiver and the toddler tend to be focused on toilet training, and, because of the close proximity of the genitalia to the urinary and anal orifices, toddlers tend to manually manipulate and inspect these areas. Masturbation is common and should be handled in a matter-of-fact-manner, thereby lessening the child’s anxiety and feelings of shame. The inquisitive nature of toddlers, combined with their need to explore, the concept of object permanence, and the desire to know about their bodies influences toddlers to behaviors related to toileting.

Domestic mimicry, or imitation of domestic/role activity, is one way toddlers express their understanding of gender roles. For example, in imaginative play, the child takes the role of “mommy,” “daddy,” or “baby,” and develops lifelong attitudes related to gender-specific behavior. Caregiver responses to boys playing with dolls or cooking in the play kitchen, and girls taking a truck a part or building houses in the mud can  have a profound influence on later role-related thinking patterns and experiences (Figure 9-6).

Figure 9-6 Toddlers engage in domestic mimicry when they repeat actions seen in caregivers.

In a similar fashion, the caregiver’s response to the toddler’s sexually related actions and questions can influence future sexual attitudes. Therefore, the caregiver needs to clarify what the child really wants to know before beginning detailed explanations. For example, when the 2V2-year-old asks, “Where does baby come from?” the child may really want to know that the baby doll came from the toy box in the bedroom, not the physiological process of reproduction (Brazelton, 1992).

Since the child’s gender identity is formulated during toddlerhood, continual rewards for responding in a manner consistent with a specific gender internalizes that identity. Gender identity is reinforced by observing same and opposite sex caregivers enact their gender roles, attitudes, and values, and by experiencing the way adults treat children of different genders differently. Refer to the Family Teaching display for guidelines to use in assisting caregivers to encourage appropriate psychological development.

 

PSYCHOSOCIAL DEVELOPMENT

The three major psychosocial tasks of toddlerhood are gaining self-control, developing autonomy, and increasing independence. Progress toward mastery can be judged through observing specific behaviors such as:

• Tolerating separation from caregiver (stays with sitter or in day care without prolonged crying/distress)

• Withstanding delayed gratification (waits, without a temper tantrum, until toy is removed from box to play)

• Increasing control over bowel/bladder function (maintains dryness for more than 2 hours)

• Utilizing socially acceptable behavior/language (controls temper tantrums/biting behaviors)

• Walking well and seeking new experiences in the environment

• Interacting with others in a less id-centric/ego-centric manner (shares toys more willingly)

In the process of mastering self-control, autonomy, and independence, the toddler must also grapple with new, confusing, and frightening situations. The way the child responds to these situations culminates in what Erikson refers to as autonomy versus shame and doubt (Erikson, 1963). Either the child masters the situation and autonomy and self-concept are strengthened, or he is unsuccessful and doubts his abilities to succeed in such situations in the future (Figure 9-8). For more information on Erikson’s theory, refer to Chapter 6 as well as Table 9-5.

COGNITIVE DEVELOPMENT

The social smile and babbling language of infancy give way to meaningful hand/arm gestures punctuated with rapidly increasing development of speech skills during the toddler years. Language ability develops rapidly. However, it is dependent upon physical maturity as well as environmental influences (parental encouragement and participation). Although most toddlers’ comprehension of words is greater than their ability to verbalize, by 36 months of age children are able to converse and begin to acknowledge different points of view. Vocabulary expands from a few words to over 900 words in 2 short years. Speaking in short sentences, using pronouns, and understanding directional commands (Table 9-6) also occur during this time. These advancements suggest the toddler is more mature than their thinking processes since the meanings of all verbalizations are not always understood. Reasoning skills also remain undeveloped during this time, although an understanding of causal relationships is emerging. Guidelines to enhance communication are found in Nursing Tips: How to Communicate with Toddlers. Cognitively, toddlers are able to recognize and distinguish between shapes of objects, but they are only beginning to classify objects into categories of use. In the mind of a toddler, all objects that look alike have the same function and are therefore treated equally. For example, a pail is used to collect sand from the sandbox, hold water to scrub the floor, and hold paint. So, in the child’s mind, if the toddler is allowed to overturn the pail of sand, then he or she is also allowed to overturn the water pail and the paint pail.

Piaget (1952) was concerned primarily with how knowledge is acquired and learning takes place; he systematically explained how children processed experiences and situations that touched their lives (culture, neighbors, other children, etc). According to Piaget (1952), toddler cognitive development encompasses three major stages divided into two phases: sensorimotor and preoperational. A summary of Piagets sensorimotor and preconceptual phase of thinking is found in Table 9-7.

 

MORAL DEVELOPMENT

Toddlers have little concept of right and wrong even though Kohlberg’s (1976) theory of moral development could be applied to toddlers because of their willful desires to make independent decisions and their increasing cognitive capacities. (Refer to Chapter 6 for more information on Kohlberg.) However, a child’s ability to actually make moral decisions is based upon multiple cognitive and social interactions that exceed the abilities of a toddler. On the other hand, Fowler (1974) does make a strong case for the consideration of early stages of faith development in this age group. Fowler defined faith as a relational phenomenon, an active relationship with another, a commitment, belief, love, and/or hope, which may be directed toward family, religion, God, or friends. As such, undifferentiated faith, as a foundation for other faith development, may occur as early as 2 years of age. Although religious rituals and symbols may not be understood at this time, the child does enjoy interacting with adults and children around simple religious stories.

 

HEALTH PROMOTION

As nurses who focus their efforts on meeting the needs of children and their families, we must provide informational and educational supports to equip caregivers to be as well prepared as possible to meet the mounting challenges presented by growing children. When caregivers are informed of expected growth patterns and developmental changes, they can anticipate what should come next, plan for the changes, and note quickly when the expected changes do not occur. Parenting is a process that one is never totally prepared to begin. Therefore, parents/caregivers of toddlers need preparation and patience to deal with the emotional periods their child will experience during these volatile 24 months of excitement and frustration. Gemelli (1996) has identified three essential roles for parents of toddlers:

• Protecting the toddler from experiencing too many episodes of distressful, over- or understimulation such as violent television shows or long periods without interaction

• Teaching the toddler how to gratify innate needs while keeping within the limits and rules set by the family and society, such as eating off of their own plate at mealtimes

• Providing empathy, encouragement, support, and love, while teaching their toddler that autonomy has limits and restrictions, such as praising the child for trying a new food item or disciplining when a disliked food item in thrown

Nurses need to provide assistance and guidance to caretakers for common issues such as nutrition, sleep, dental hygiene, safety and injury prevention, health screening, negativism, ritualism, regression, discipline, sibling rivalry, temper tantrums, toilet training, child (day) care, and play. Each of these topics will be addressed briefly.

Nutrition

The toddler’s ability to chew and swallow as well as use utensils also improves during this time. Caretakers who understand these changes will be better able to introduce new foods reflecting the child’s abilities. It is also, however, important to avoid foods that may be major choking hazards (pieces of hot dogs, popcorn, nuts, hard candy); (Forgac, 1995; Feeding the Toddler, 2001).

Caregivers should consider the toddler’s abilities by cutting food into small bits, offering dipping sauces, and serving small portions. Most adult food can be provided with some modifications; however, toddlers rarely like new food the first time it is introduced. Juice should be limited to 4 ounces per day, because it is a nutrient-dense food that often replaces calories that should come from more nutritious foods. Since there is an increased incidence of severe peanut allergy in young children, caretakers should be instructed to withhold any food item containing peanuts until 3 years of age.

Mealtimes continue to be messy during this age. Toddlers are still in the process of becoming proficient with a spoon and often spill. Caregivers should be encouraged to provide praise and positive reinforcement since scolding causes tension and stress. Eating habits are established in the first 2-3 years, and forcing food or creating periods of extended tension at mealtime are not healthy. Food issues tend to occur about the same time that the toddler is being encouraged to sit with the family during mealtime, often leading to explosive verbal exchanges, especially during the evening meal.

Caregivers tend to become concerned about the child’s decreased food intake and/or the fact that, for weeks, the toddler may eat only cereal (or go on other food jags).

Caregivers need to be assured the child will not starve and generally will eat when hungry. A general rule of thumb to use in determining adequacy in the meal is to offer 1 tablespoon of each food group for each year. For example, a 3-year-old would need 3 tablespoons of meat, 3 tablespoons of carbohydrate (rice or potato), 3 tablespoons of vegetable, and 3 tablespoons of fruit.

Different strategies may also be used. Offering smaller amounts of food may encourage the toddler to ask for more. For others, frequent nutritious snacks throughout the day may be more enjoyable. Nurses should also remind caretakers to acknowledge the toddlers ritualistic needs (e.g., same plate, same cup). Encouraging the toddler to explore the world of food should be accompanied by clear limits. The Family Teaching box on picky eaters provides some helpful guidelines in coping with these stressors.

See also Nutrition Guide for Toddlers, Toddler Nutrition, New Iron Intake Guidelines for Babies and Toddlers

Helpful feeding information for your toddler:

The toddler (ages 1 to 3 years) phase can often be challenging when it comes to feeding. Several developmental changes occur at this time. Toddlers are striving for independence and control. Their growth rate slows down and with this comes a decrease in appetite. These changes can make meal time difficult. It is important for parents to provide structure and set limits for the toddler. The following are suggestions to help manage mealtimes so that the toddler gets the nutrition he/she needs:

• Avoid battles over food and meals.
• Provide regular meals and snacks.
• Be flexible with food acceptance as toddlers are often afraid of new things.
• Be realistic about food amounts. Portion size should be about one-fourth the size of an adult portion.
• Limit juice intake to about 4 to 6 ounces per day.
• Dessert should not be used as a reward. Try serving it with the rest of the food.
• Take the food easy for your toddler to eat:

o       Cut food into bite-sized pieces.

o       Make some foods soft and moist.

o       Serve foods near room temperature.

o       Use ground meat instead of steak or chops.

o       Use a child-sized spoon and fork with dull prongs.

o       Seat your child at a comfortable height in a secure chair.

Prevent choking by:

©       slowly adding more difficult-to-chew foods.

©       avoiding foods that are hard to chew and/or swallow such as nuts, raw carrots, gum drops, jelly beans, and peanut butter (by itself).

©       modifying high-risk foods: cut hot dogs in quarters, cut grapes in quarters, and cook carrots until soft.

©       always supervising your child when he/she is eating.

©       keeping your child seated while eating.

 

Sleep

Most 2-year-olds require 12-14 hours of sleep each day with a nap generally in the afternoon (some toddlers require a morning nap as well). Sleep is important to reenergize the toddler and promote growth and development. Lack of sleep makes the toddler feel tired, cranky, and irritable. To help the toddler obtain adequate sleep and rest, caretakers can develop naptime and bedtime routines.

Bedtime protests can be reduced by beginning a winding down period when toddlers are bathed, cuddled, and/or read to prior to being put to bed for the night. Firm consistent limits are needed when the child resists going to bed and dawdles or stalls (asking for water). Some toddlers wake in the middle of the night and may have trouble returning to sleep. It is important to let the child cry for a short time since this assists the child to learn self-calming and comforting measures. If crying continues, caregivers can offer a hug, backrub, or drink before leaving the room again. A favorite blanket or toy coupled with a calm reassurance can also help facilitate the child’s return to sleep. Nightmares are also common in toddlerhood since their dreams seem very real (Grover, 2001a). The toddler will generally respond to gentle reassurances and most often will return to sleep and will not remember the dream the next day.

Dental Health

In addition to routine health care visits, toddlers should also see a dentist. The child’s first visit should be soon after the first teeth erupt at about 1 year of age. An important aspect of the visit is assessment of oral health, education of caretakers regarding correct methods of dental hygiene, and counseling on strategies to prevent caries (Grover, 2001c).

Young children are unable to brush all areas of the mouth, and as a result, caretakers will need to assume some responsibility for effective teeth cleaning (Figure 9-11). Toddlers may use only water, disliking the taste and foam of toothpaste. There is, however, some danger if fluoridated toothpaste is swallowed, so caregivers should be cautioned that, if toothpaste is used, it be used sparingly. Caregivers should select small toothbrushes that are soft with short, rounded bristles. After cleansing the teeth, flossing is recommended to remove debris below the gum line and prevent gingivitis (Grover, 2001c). A disclosing agent may help identify areas where plaque exists. Teeth should continue to be brushed until the dye (generally red) is gone.

The use of fluoride is an effective method to lessen the extent of tooth decay and promote tooth health (American Academy of Pediatrics Committee on Nutrition, 1986). Tooth enamel resists developing caries when adequate amounts of fluoride are consumed before the teeth erupt. The nurse should educate caregivers regarding correct administration of fluoride supplements if it has been determined that fluoridation of water does not exist in the community (American Academy of Pediatric Dentistry, 1996).

Safety Promotion and Injury Prevention

The coupling of an inquisitive mind and a tottering, but mobile body places toddlers at increased risk for injury through accidents. The types of accidents and injuries experienced are directly related to the child’s developmental progression (Table 9-8). Most injuries and deaths to toddlers are due to airway obstruction, poisonings, drowning, falls, burns, and automobiles (Online Safety Project, 2001).

Auto Safety

State and federal laws related to child safety seats and seat belt use have produced a marked decrease in injuries and deaths among children; however, the laws are of little value unless caregivers follow them. Toddlers should always be strapped into a child-safety seat, appropriate for weight and size (Henson, Hadfield, & Cooper, 1999; Thompson & Emslie, 2000). The safety seat should be placed in the back seat of the vehicle. Toddlers should not ride in the front seat of a vehicle that has an air bag, unless they have specific medical conditions (i.e., tracheotomies, uncontrolled seizures, severe respiratory problems) that require constant observation. In these limited cases, the child should be placed in an appropriate front seat car seat and the air bag mechanically disabled (Flaherty & Snyder, 1998). A booster seat (one without side arms) is not appropriate until a child weighs at least 30 pounds. Transition of a child from a booster seat to lap-shoulder belts should not occur until the child reaches at least 4 years of age, 40 pounds, and/or 40 inches in height.

Nurses should review child passenger safety information with caregivers at every opportunity. The Child-Occupant Safety Checklist (Table 9-9) could become a routine part of your teaching approach.

Keeping toddlers from darting into streets in front of vehicles requires constant attention and repeated teaching. By 3 years of age, the child should begin to understand the concept of stopping and looking both ways before moving into a street. Even if toddlers do not understand the concept of oncoming danger, repetition of the stop-look sequence helps build the concept of safety.

Home and Environmental Safety

Homes and surrounding play areas need to be childproofed to prevent drowning, falls, and accidental poisonings (Figures 9-12 and 9-13). Even when caregivers make a conscious effort to protect toddlers, toddlers needs to learn which things they may and may not play with in a home. All medications and toxic substances (e.g., gasoline, pesticides, household cleaning products) must be kept out of the child’s reach and preferably locked away. These items should never be stored in familiar containers (such as soft drink bottles) and should have a “Mr. Yuck” or similar poison alert symbol affixed. Never tell a child that medication is candy to encourage taking it, and never leave medications (including vitamins) sitting on tables, or in the diaper bag or purse. Homes where toddlers live or frequently visit should have a bottle of syrup of ipecac in case a child accidentally ingests a toxic substance. However, caregivers should be instructed to administer syrup of ipecac only after consulting a Poison Control Center.

Toy Injuries/Gun Safety

Injuries related to the toys that children play with are central to toddler safety (Figure 9-14). Toys must be strong, safe, and large enough to prevent swallowing. Popped balloons are a major culprit, and for this reason, the use of latex balloons should be discouraged. Mylar, foil-type balloons are the only ones recommended as safe for young children.

Another category of concern to toddler safety is gun safety. It is impossible to teach toddlers the differences between toy guns and real guns since their cognitive abilities are not well enough developed to comprehend gun safety. Therefore, if guns are in the house, they must always be kept locked away from the inquisitive toddler (Society of Pediatric Nurses, 1998).

 

ROUTINE HEALTH SCREENINGS

Routine health visits to a primary health care provider begun in infancy should continue through toddlerhood. Caregivers should be encouraged to schedule well-child visits at 15, 18, 24, and 36 months of age; additional visits should be made if illness occurs. The routine visits are needed for health monitoring and updating or beginning immunizations if not initiated during infancy. The American Academy of Pediatrics (2000) has recently published a revised immunization schedule, which indicates toddlers need boosters of diphtheria, tetanus, and pertussis (DTP, or DtaP), H. influenza (HIB), polio, and hepatitis B (if not received at 6 months of age) by 18 months of age. They also need initial doses of measles, mumps, rubella (MMR) and varicella/chicken pox (Var) vaccines. Caregivers should be encouraged to complete the initial immunization series in a timely manner to protect their child and to prevent delayed school entry.

Health screening should always include a complete physical examination (including blood pressure, height, and weight), evaluation of hemoglobin (for iron-deficiency anemia), dental evaluation, and vision and hearing assessment. Before the anterior fontanel closes, the head circumference should be measured. The American Academy of Pediatrics recommends that screening serum lead levels be obtained in children exhibiting poor growth patterns or neurological irritability, or in those living in high-risk areas (AAP, 1998).

Negativism

Negativism is an expression of the toddler’s constant search for autonomy. The toddler resents being given directions and/or not being allowed to explore what is desired in an expanding environment. Characteristically, the toddler seems to delight in doing the opposite of what is asked and responding “no” to all requests. Caregivers are frequently frustrated when trying to deal with toddler negativism and are delighted to learn that this period typically passes by about 30 months of age.

Caregivers, however, will have to select their own method of dealing with their child’s negativism. As with any attention-seeking behavior, it is best to ignore the action as much as future behavior-related issues.

Ritualism and Regression

As disrupting as negativism can be, another characteristic developing simultaneously is ritualism, or the need to maintain sameness (same cup, same spoon). The toddler needs stability within the expanding environment and to know, when off in a new play area, familiar people and places will still be available (Figure 9-15). Rituals, such as mealtime and bedtime routines, provide repetition where the child may gain comfort and security. When rituals are disrupted, as when a child is ill or hospitalized, the child experiences stress, responds by exerting autonomy, and frequently regresses (returns to a earlier, safer, more familiar behavior) to dependence and negativism (Eriksons concept of autonomy versus shame and doubt) to cope with the situation.

Many caregivers feel they become slaves to the schedules of their 2-year-old. When a toddler demands things be done in the same way at the same time, the child is not acting out of stubbornness, but asking for needs to be met.

Routines provide a sense of security and give a framework to master new skills while providing a sense of control over the environment. The best initial approach is to ignore regression while complimenting the child on positive attributes and behaviors. When caregivers assess the toddler’s behavior, they often assume regression is an act of defiance or willful disobedience. Since the loss of a newly acquired skill is frightening to the toddler, regression should be disciplined cautiously.

It not uncommon for toddlers to demonstrate a variety of behaviors when stressed. These behaviors include aggression, avoidance, distraction, isolation, seeking information, self-consoling activities, and emotional expressions. That is why toddlers may use a security blanket, have a favorite teddy bear, ask many questions, argue, cry, or have temper tantrums (Ryan-Wenger, 1992).

Discipline

 In light of their evolving concept of ritualism and the need for familiar routines, toddlers are assisted in developing self-control by consistently applied discipline. Regardless of the methods used, teaching the reasons for the discipline is essential (Blum & Williams, 1995).

Limit setting (letting the child know what they are able to do and not do in a situation) is an important part of toddler discipline since we all tend to function better when both the expectations and limits defining actions are known. These limits may be established by the child, adult caregivers, or the external environment. Caregivers who provide the toddler with clear and concise limits facilitate autonomy development and help the child gain a sense of order, control, and security (Gottesman, 2000).

Caregivers should agree upon both the limits not to be exceeded and the type of discipline used when established boundaries are pushed. The American Academy of Pediatrics (1998) identifies three essential components of successful and effective discipline: (1) a supportive and loving relationship between parent(s) and child, (2) use of positive rein forcement to promote desired behaviors, and (3) removing reinforcement to reduce and eliminate undesired behaviors.

To support and facilitate consistency, all caregivers, including grandparents and babysitters, should be told about established limits and disciplinary actions. Providing consistent discipline is critical for understanding, gaining responsibility, and experiencing positive behavioral outcomes. Refer to the Family Teaching box for more information. The type of discipline utilized will vary from family to family and culture to culture; however, approximately 90% of parents in the United States use corporal punishment (physical punishment) in disciplining their children (APA, 1998). Corporal punishment may bring about an immediate change in behavior, but the long-term effect is questionable for toddlers. Use of caregiver role modeling (Bandura, 1986) has been successful in disciplining toddlers, but requires the child to (1) see the correct behavior enacted, (2) remember what the role model did, (3) be physically able to repeat the role model’s action and (4) be motivated to engage in the modeled behavior. This works especially well where a strong trust relationship exists with the role model. Role modeling, use of the teaching process, scolding, ignoring, and/or time out (placing the child in a nonstimulating environment) seem to be among the most widely used methods of achieving behavioral change with toddlers (Berkowitz, 2001a)

 

 Toddler Discipline

1. Nurses should never physically discipline a child. (Physical punishment may legally be administered only by a parent or legal guardian and the type and degrees of such punishment are currently under scrutiny.) The American Academy of Pediatrics’ (1998) statements related to spanking, discipline, and punishment are accepted as the professional standard and can be found on their website.

2. If the child is hospitalized, discuss with caregivers how you may support their methods of discipline. Explain that hospitalized children frequently display regressive behavioral patterns, and carefully think before implementing any disciplinary measures related to regressive behavior.

3. If you observe inappropriate verbal or physical discipline, as a professional you are mandated to report it. The reporting mechanism will differ from state to state, but your responsibility does not change.

 

Temper Tantrums

Temper tantrums are outward explosive reactions to inward stressful or frustrating situations that are a normal part of toddler life. Between 2 and 3 years of age, the child is faced with new environments, new rules, and new fears.

Toddlers need to express their feelings, wishes, and frustrations, but lack the language skills to do this. All of these new experiences, coupled with the child’s quest for autonomy, may create tension and erupt into a tantrum. Tantrums are ways toddlers say, “I have needs, I am important, I need to have some control.” A typical temper tantrum—occurring when the toddler can’t control his or her emotions, feels overwhelmed, or does not get what is wanted when it is wanted—may involve crying, screaming, falling onto the floor, kicking the feet, flailing the arms, banging the head, and breath holding (Grover, 2001b). Head banging requires intervention if it is continuous and/or unsafe, and to prevent injury, the caregiver should hold the child’s head, make few comments (to prevent reinforcement of the negative behavior), and/or provide a protective mat or pillow. Beyond this, as with any attention-seeking behavior, the tantrum should be ignored. Speaking softly and calmly, recognizing the child’s feelings, and holding can help. When breath holding occurs and the child appears to faint or stop breathing, caregivers frequently become frightened and rush into frenzied action, which only reinforces the tantrum behavior. Therefore, caregivers must be taught that breath holding is usually harmless. The child may “faint,” but will automatically begin breathing again as soon as carbon dioxide builds up and stimulates the respiratory center. Although caregivers are not encouraged to intervene during a tantrum, they should remain close by to prevent traumatic injuries. It is also helpful to remove the child from public attention.

At the conclusion of the tantrum, the caregiver should offer a toy or optioot related to the incident-producing difficulty. (“Why don’t we play with your new tea set?”) This will redirect the toddler’s attention. Disciplining a child after a tantrum usually is of little value. However, if the caregivers have told the child there would be a consequence to this behavior, they should follow through as promised. Tantrums cannot always be controlled, but caretakers can take measures to lessen their frequency and/or intensity, including developing a regular schedule for the toddler, reducing the need to say “no,” allowing choices, rewarding good behavior, and staying calm. Tantrums can sometimes be avoided by using time-outs or by placing a child in a bedroom before the behavior escalates. Temper tantrums are considered a normal developmental response of toddlerhood but should disappear by 4 years of age.

TOILET TRAINING

A major factor contributing to the toddler’s goals of independence and autonomy is accomplishing bowel and bladder control. Success, however, depends on the readiness of both the child and the caregiver. Caregivers who understand normal child growth and development will have more realistic expectations and less frustration during toilet training.

Myelinization of the spinal cord and development of sphincter muscle control occur at approximately 12-18 months of age, and must be complete prior to beginning bowel and bladder training since the average toddler is ready to begin toilet training at approximately 18-24 months. The time to begin toilet training, however, varies from culture to culture and family to family. Nurses should educate parents about the signs of readiness for toilet training, which include the ability to demonstrate cognitive awareness of elimination (diaper is wet), follow directions and communicate understanding of eliminatioeeds to the caregiver (pulls on diaper, asks for diaper change), remain dry for longer periods of time (more than 2 hours), independently dress and undress, and sit, squat, and walk well (Berkowitz, 2001c; Vessey, 2000).

Bladder control is often more difficult to attain than bowel control. The toddler usually has only one to two bowel movements per day, but urinates much more frequently. Often, accidental urinary incontinence occurs because the toddler becomes so involved in play activities that the urge to urinate is ignored until it is too late to reach the bathroom. When the toddler is attempting to remain dry and learn bowel control, an emotional tug-of-war often develops between the child and the caregivers, leaving both frustrated and angry. Punishment and coercion can lead to shame and feelings of inferiority. A strategy that is often helpful is giving the child control over the process. Telling the child how the body makes “pee” and “poop” daily and helping the toddler succeed can encourage participation and responsibility. A relaxed approach, with positive reinforcement and praise, will aid in toilet training, as will avoiding constant reminders and providing incentives for using the toilet correctly. Recording the child’s progress and not punishing accidents are also important. Consistent day and night dryness should be achieved by 5 years of age, or further evaluation for physical and/or psychological problems is warranted (Berkowitz, 2001c).

Stress may either interfere with toilet training or precipitate regressive bowel/bladder continence. Caregivers need to be informed that such regressions are usually temporary and understanding, gentle support, reinforcement, and encouragement will assist the toddler regain a sense of independence and success.

See also Potty Training in a Day, The Great Potty Debate

Child Care

Placing the toddler in a child care setting if both parents are employed outside the home may be necessary in some situations. The child care setting may pose additional threats to the toddler’s health and well being. Caregivers might seek support from professionals that use of such facilities is perfectly acceptable in today’s society.

 

NURSING MANAGEMENT

The nurse’s role in toddler health promotion is critical. Education should provide ideas, suggestions, and concepts surrounding growth, development, and parenting skills. This knowledge will allow caregivers to become independent in promoting health with respect to nutrition, sleep, dental needs, safety, elimination, and growth and development. Ideally, the toddler should be seen consistently by the same health care provider since the most accurate clinical judgments are made not on one observation alone, but rather based on trends over time.

 

 

References

а) Basic

 

1. Manual of Propaedeutic Pediatrics / S.O. Nykytyuk, N.I. Balatska, N.B. Galyash, N.O. Lishchenko, O.Y. Nykytyuk – Ternopil: TSMU, 2005. – 468 pp.

2. Kapitan T. Propaedeutics of children’s diseases and nursing of the child : [Textbook for students of higher medical educational institutions] ; Fourth edition, updated and

    translated in English / T. Kapitan – Vinnitsa: The State Cartographical Factory, 2010. – 808 pp.

3. Nelson Textbook of Pediatrics /edited by Richard E. Behrman, Robert M. Kliegman; senior editor, Waldo E. Nelson – 19^th ed. – W.B.Saunders Company, 2011. – 2680 p.

 

b) Additional

1.  www.bookfinder.com/author/american-academy-of-pediatrics 

2. American Academy of Pediatrics Task Force on Mental Health : Enhancing pediatric mental health care: strategies for preparing a primary care practice. Pediatrics 2010; 125(Suppl 3):S87-S108.

3. Glascoe FP, Leew S: Parenting behaviors, perceptions and psychosocial risk: impact on child development. Pediatrics 2010; 125:313-319.

4. www.bookfinder.com/author/american–academy–of–pediatrics 

5. www.emedicine.medscape.com

6. http://www.nlm.nih.gov/medlineplus/medlineplus.html