2 critical time periods of weight and linear growth are in infancy and adolescence.

Best indication for overall good health in infancy is a steadily increasing height, weight, head and chest circumference. These are plotted on a growth chart and monitored from birth to 2 years of age. It is used to compare with other children and is individualized.

How do they know when there is a problem? When the weight falls behind height by 2 standard deviations and when the pattern of weight and height percentiles indicate a decrease.

Physical Growth:

Height:

Average birth length is 20 inches.

Height increases 50% by 1st year.

Gain about 1 inch/month for 1st 6 months.

1/2 inch/month for next 6 months.

Weight:

By 5-6 months should be doubled.

By 1 year, should be tripled.

Head Circumference:

At birth, greater than chest circumference.

Average is 13 3/4 inches.

By end of 1st year head and chest circumference is equal. (18").

By end of 2 years, chest becomes larger.

In daily assessment do head circumference.

In 1st 6 months, increases about 1/2 inch/month.

Last 6 months, increases about 1/4 inch/month.

Fontanelles:

Posterior closes at 2-3 months.

Anterior closes at 12-18 months.

Vital signs:

Pulse at birth = 120-160.

Pulse by end of 1st year = 100-120.

Resps = 20-50, average is 30.

Abdominal respirations = diaphragmatic.

BP average is 85/60 for 1st year.

Temp is usually axiallary except for first one.

Axillary is 1 degree less than oral.

Rectal is 1 degree higher than oral.

When elevated, take more frequently.

Teeth: dentition.

At 3 months, begin to drool (more saliva).

Haven’t learned to coordinate swallowing.

Teeth begin to erupt at 6 months.

First set is called deciduous or primary teeth.

How teeth come in may affect speech.

Full set of primary is complete by 30 months or 2 1/2y.

Have about 6 by end of 1st year.

Red, swollen, and painful gums accompanies teething.

Fever and diarrhea is not typical with teething.

If they do have diarrhea or a fever, it is due to low maternal antibodies; therefore resistance to infection is lower.

Topical anesthetic can be used.

Cool teething rings numb sore areas.

Developmental Milestones:

These norms are valuable for comparing and predicting normal development. They are still going to have an individual pattern.

Gross Motor:

Posture

Head control. From 1 to 3 months can turn side to side and can follow an object in front of their face. By 4 months if lying on stomach can lift head up and chest comes up 90 degrees. By 4 to 6 months, head control is well established.

Rolling over. From 3 to 6 months, baby can roll from stomach to back and vice versa. Don’t leave unattended. By 7 months, have parachute reflex = trying to hold it self up, arms and legs and head will go out, protective measure.

Sitting. By 6 months can sit without support for a short time. By 8 months can sit well alone. By 10 months can go from prone to a sitting position.

Crawling. By 9 months because flexor muscles are stronger. Can pull themselves up using sides of furniture.

Walking. By 11 to 12 months can walk holding onto furniture. By 13 months can walk well by themselves.

Fine Motor:

Ability to use hands and fingers in prehension = ability to grasp an object. Develop from proximodistal.

Newborn usually keeps their hands in a grasp reflex.

3 months normally hold hands open most of the time.

3 months will swipe at an object but cannot grasp it.

5 months voluntarily grasp an object.

7 months banging things together.

7 months palmer grasp.

8 months prehension occurs.

8-9 months crude pincer grasp. Forefinger in opposition to thumb.

10-11 months neat pincer grasp. This is why at 10 months can find minute things and put in their mouth. Excellent time for finger foods. Popcorn is a no-no.

12 months can build a 2-block tower.

Sensory Development:

Touch:

Form of stimulation.

How environment is learned.

Important to provide active and passive touch.

Active = toys, rattles, textures.

Passive = caregivers touch.

Taste:

Prefers sweet over sour.

Smell:

Learn to smell breast milk and associate it with mom.

Respond to irritating odors.

Hearing:

Can distinguish mom’s voice from stranger’s.

8 months, will attempt to imitate sounds.

10 months, able to recognize name and turns head when hears it.

Sight:

Eye contact is first social contact.

Can see and discriminate patterns.

1 month can see 18 inches away.

1 to 3 months likes the human face.

3 to 6 months, smiles at familiar faces, but not a strangers.

Eye Color:

Not established until 6 to 12 months.

Psychosocial Development:

Trust vs. Mistrust.

Quality of caregiver and child’s relationship and consistency of care is important.

Attentive and timely care will teach them to trust their environment.

When a child’s needs are met consistently, they develop faith and optimism.

An infant needs routine and sameness of experience. Needs a workable schedule.

Needs same nurse.

Read same stories over and over again because they learn to trust the pattern and outcome.

Cognitive Development:

Sensorimotor phase: ages 0 to 2 years.

Reflex to imitative to repetitive behavior.

1 to 4 months, can’t differentiate, trial and error behavior.

4 to 8 months, attention shifts to objects.

3 crucial events from birth to 12 months:

1. Learns to separate themselves from other objects.

2. Learning object permanence.

3. Begins to use symbols or mental representations. The recognition of these symbols is the beginning of the understanding of time and space.

Play:

Solitary play. No interaction with others.

Will play with mom and dad or someone they know.

Stimulation and Play:

1 to 3 months:

Likes voices and music for auditory stimulation. Crib mobiles and looking face-to-face stimulates visually. Tactile stimulation is achieved by stuffed animals and other toys with texture. Other things they like are to be carried and rocked, rattles, mirrors, and moving toys. Always remember toy safety.

4 to 6 months:

More aware of self and environment. They laugh and "talk" a lot. Likes blocks, crib gym, toys that imitate animal sounds and all toys that make noise.

7 to 9 months:

Begin stranger anxiety, a.k.a. separation anxiety (6-8). Do not confront abruptly. Likes peek-a-boo, patty cake and toys that disappear and re-appear.

10 to 12 months:

Learning to be more independent. Likes toys they can put one inside the other, toys that can be pushed, containers with removable lids and large puzzles.

Nutrition:

1st 6 months diet is solely milk.

If breast feeding, needs only a supplement of fluoride (only if not on city water) and at 4 months, will need some iron because fetal stores of iron are depleted.

If baby cries, this does not mean it is hungry, unless it is losing weight.

Formula fed baby should be on formula for 1 year.

When put on cow’s milk, use whole milk only. Infant needs the essential fatty acids necessary for growth of nervous system.

Obesity is a problem. They need to have water also.

Advance - formula with 20% fewer calories.

Also if gaining, can dilute formula.

Substitute water for formula for a few feedings.

Give nipple with a smaller hole.

Should not be on a diet, just slow weight gain down.

Weaning: substitute cup for bottle or breast. Should not do it cold turkey. Will show readiness at 5 to 6 months. 8 or 9 months, want to drink out of a cup because everyone else is. At 1 year, can hold and drink with assistance.

Nursing bottle syndrome: when put baby to bed with bottle of milk causes dental caries.

Introducing food too early could expose them to allergies. Stomach cannot digest before a certain age.

Foods to Introduce:

1. Cereal. Fortified with iron. May be physiologically anemic. 1 to 2 teaspoons mixed with breast milk, formula or water. If too thick may cause colic. Keep on cereal up to 18 months because of iron content. Start with rice cereal because it has less allergens.

2. Vegetables or fruit. Fruit juices may need to be diluted. Should have vitamin C to help with the absorption of iron. Leave on one for four days so you know if it causes an allergy. Should start with vegetables first. Should puree food. At 9 months can start with junior food with more consistency. Can feed table food, but it may have too much salt and seasonings. Common food allergy is protein in egg whites. Teach families that children will be messy.

Sleep/Rest Needs:

Sleeps 20-22 hours of the day.

Later will take 2 naps/day.

Begin a bedtime ritual.

Establish that crib is to sleep not to play.

When wake up in the night, check on them, but don’t take out.

Rely on external constraints to learn behavior - use no-no sternly.

Corporal punishment does not work at this age.

Discipline needs to be appropriate.

Immunization Schedule:

Page 195. Must know.

Contraindications:

A. Severe febrile illness other than common cold.

B. Immunocompromised infant or family member.

Can be deadly to either because of live virus.

Malignancy, chemo, radiation, steroids.

C. Severe sensitivity to eggs.

D. Gastroenteritis - no OPV because polio virus must be colonized in the intestines to produce an immune response.

E. Blood transfusion or gamma globulin in previous 2 months.

Will not get MMR because it is passive immunity and they will be getting someone else’s blood. Will need to wait 6 weeks.

Care Safety:

Rear facing, in middle of back seat.

7-9 months or 17-20 pounds, can turn around.

4 feet, 5 years, 40 pounds can be in just seat belt.