PEDS: Exam 2

TODDLERS: Gross Motor

-The major gross motor skill during the toddler years is the development of locomotion. By 12 to 13 months of age, toddlers walk alone using a wide stance for extra balance, and by 18 months of age they try to run but fall easily -By the end of the second year, they can stand on one foot, walk on tiptoe, and climb stairs with alternate footing.

TODDLERS: Fine Motor

-Activities occur less in isolation and more in conjunction with other physical and mental abilities to produce a purposeful result. For example, the toddler walks to reach a new location, releases a toy to pick it up or to choose a new one, and scribbles to look at the image produced. The possibilities of the exploration, investigation, and manipulation of the environment—and its hazards—are endless.

INFANTS: PIAGET: Phase 1

(1)The first stage, from birth to 1 month, is identified by the infant's use of reflexes. At birth, infants' individuality and temperament are expressed through the physiologic reflexes of sucking, rooting, grasping, and crying. The repetitious nature of the reflexes is the beginning of associations between an act and a sequential response. When infants cry because they are hungry, a nipple is put in the mouth and they suck, feel satisfaction, and sleep. They are assimilating this experience while perceiving auditory, tactile, and visual cues. This experience of perceiving certain patterns, or "ordering," provides a foundation for the subsequent stages.

INFANTS: PIAGET: Phase 2

(2)The second stage, primary circular reactions, marks the beginning of the replacement of reflexive behavior with voluntary acts. During the period from 1 to 4 months of age, activities such as sucking or grasping become deliberate acts that elicit certain responses. The beginning of accommodation is evident. Infants incorporate and adapt their reactions to the environment and recognize the stimulus that produced a response. Previously they cried until the nipple was brought to the mouth. Now they associate the nipple with the sound of the parent's voice. They accommodate this new piece of information and adapt by ceasing to cry when they hear the voice—before receiving the nipple. What is taking place is a realization of causality and a recognition of an orderly sequence of events. The environment is taken in with all of the senses and with whatever motor ability is present.

INFANTS: PIAGET: Phase 3

(3)The secondary circular reactions stage is a continuation of primary circular reactions and lasts until 8 months of age. In this stage, the primary circular reactions are repeated and prolonged for the response that results. Grasping and holding now become shaking, banging, and pulling. Shaking is performed to hear a noise, not solely for the pleasure of shaking. The quality and quantity of an act become evident. More or less shaking produces different responses. Understanding of causality, time, deliberate intention, and separateness from the environment begins to develop

INFANTS: PIAGET: Phase 4

(4) During the fourth sensorimotor stage, coordination of secondary schemas and their application to new situations, infants use previous behavioral achievements primarily as the foundation for adding new intellectual skills to their expanding repertoire. This stage is largely transitional. Increasing motor skills allow for greater exploration of the environment. They begin to discover that hiding an object does not mean that it is gone but that removing an obstacle will reveal the object. This marks the beginning of intellectual reasoning. Furthermore, they can experience an event by observing it, and they begin to associate symbols with events (e.g., "bye-bye" with "Mommy or Daddy goes to work"), but the classification is purely their own. In this stage, they learn from the object itself; this is in contrast to the second stage, in which infants learn from the type of interaction between objects or individuals. Intentionality is further developed in that infants now actively attempt to remove a barrier to the desired (or undesired) action. If something is in their way, they attempt to climb over it or push it away. Previously, an obstacle would cause them to give up any further attempt to achieve the desired goal.

TODDLERS: Development of Body Image

-As in infancy, the development of body image closely parallels cognitive development. -During the second year, children recognize themselves in a mirror and make verbal references to themselves ("Me big") -They also learn that certain parts of the body have various meanings (e.g., during toilet training, the genitalia become significant, and cleanliness is emphasized) -Gender identity is developed by 3 years of age *By this time, the child also begins to remember events with reference to their personal significance, forming an autobiographic memory that helps establish a continuous identity throughout the events of life. -Toddlers also have unclear body boundaries and may associate nonviable parts such as feces with essential body parts. This can be seen in a toddler who is upset by flushing the toilet and watching the stool disappear. -toddlers forcefully resist procedures such as examining the ear or mouth and taking an axillary temperature. The procedure itself (e.g., taking vital signs) does not hurt the child, but it represents an intrusion into the child's personal space, which elicits a strong protest -Nurses can assist parents in fostering a positive body image in their child by encouraging them to avoid negative labels such as "skinny arms" or "chubby legs"; such self-perceptions are internalized and can last a lifetime. Body parts, especially those related to elimination and reproduction, should be called by their correct names. Respect for the body should be practiced. -toddlers can use symbols to represent objects, but their thinking may lead to inaccuracies. For example, if someone who is pregnant is called "fat," they describe all "fat" women as having babies.

TODDLERS: *Piaget* 12-24 months

-Continuance of sensorimotor in infancy -The beginning of rational judgement and intellectual reasoning -The child further differentiates self from objects -Children are able to recognize different shapes and their relationship to one another -Children are also aware of space and the relationship of their body to dimensions, such as height. They stretch, stand on a low stair or stool, and pull a string to reach an object. -object permanence -Imitation displays deeper meaning and understanding. There is greater symbolization to imitation. Children are acutely aware of others' actions and attempt to copy them in gestures and words. Domestic mimicry (imitating household activities) and gender-role behavior become increasingly common during this stage, especially during the second year. Identification with the parent of the same gender becomes apparent by the second year and represents the child's intellectual ability to identify different models of behavior and imitate them appropriately -The concept of time is still embryonic; but children have some sense of timing in terms of anticipation, memory, and a limited ability to wait. They may listen to the command, "Just a minute," and behave appropriately. However, their sense of time is exaggerated; 1 minute can seem like 1 hour. Toddlers' limited attention spans also indicate their sense of immediacy and concern for the present.

TODDLERS: Sensory Changes

-Full binocular vision is well developed, and any evidence of persistent strabismus requires professional attention as early as possible to prevent amblyopia. -Depth perception continues to develop but, because of the child's lack of motor coordination, falls from heights are a persistent danger. -Toddlers visually inspect an object by turning it over; they may taste it, smell it, and touch it several times before they are satisfied with their investigation. -They shake it to see if it makes noise and vigorously test its durability. specific taste preferences. Toddlers are much less likely than infants to try new foods—appearance, texture, or smell, not just their taste.

INFANTS: Preventing plagiocephaly

-Infants should be placed prone on a firm surface during awake time (tummy time), which prevents plagiocephaly and facilitates development of upper shoulder girdle strength; the latter helps in the progressive development of movements such as rolling over and starting to rise up on all fours, which are precursors to crawling and eventually walking -A total of 30 to 60 minutes of supervised tummy time per day in infants younger than 6 months of age is recommended -Additional measures to prevent positional plagiocephaly include avoiding excessive time spent in car restraint seats, infant seats, and bouncers -When a nurse or parent notices plagiocephaly, a consultation with the primary health care practitioner is recommended to evaluate the head shape and ascertain the need for early intervention.

INFANTS: Colic complications

-One important nursing intervention (before or after an organic cause has been eliminated) is reassuring both parents that they are not doing anything wrong and that the infant is not experiencing any physical or emotional harm - Colicky infants may be at increased risk for being shaken or otherwise abused by their caregivers and experiencing traumatic brain injury

INFANTS: Colic

-Paroxysmal abdominal pain -The condition is defined by the rule of threes: crying and fussing for more than 3 hours per day occurring more than 3 days per week and for more than 3 weeks in a healthy infant -Colic is more common in infants younger than 3 months of age than in older infants, and infants with difficult temperaments are more likely to be colicky. - Infants with cow's milk allergy (CMA) symptoms have a high rate of colic (44%), and eliminating cow's milk products from the infant's diet can reduce the symptoms -The initial step in managing colic is to take a thorough, detailed history of the usual daily events. Areas that should be stressed include (1) the infant's diet; (2) the diet of the breastfeeding mother; (3) the time of day when crying occurs; (4) the relationship of crying to feeding time; (5) the presence of specific family members during crying and habits of family members, such as smoking; (6) the activity of the mother or usual caregiver before, during, and after crying; (7) the characteristics of the cry (duration, intensity); (8) the measures used to relieve crying and their effectiveness; and (9) the infant's stooling, voiding, and sleeping patterns. Of special emphasis is a careful assessment of the feeding process via demonstration by the parent. -If CMA is suspected, breastfeeding mothers should follow a milk-free diet for a minimum of 3 to 5 days in an attempt to reduce the infant's symptoms. Caution mothers that some nondairy creamers may contain calcium caseinate, a cow's milk protein. If a milk-free diet is helpful, lactating mothers may need calcium supplements to meet the body's requirement. Bottle-fed infants may improve with the same dietary modifications as for infants with CMA. -Usually disappears spontaneously within 3-4 months

INFANTS: Language Development

1 to 3 Months •Reflexive smile at first, becoming more voluntary; sets up a reciprocal smiling cycle with parent. Cooing. 3 to 4 Months •Crying becomes more differentiated. Babbling is common. 4 to 6 Months •Plays with sound, repeating sounds to self. Can identify mother's voice. May squeal in excitement. 6 to 8 Months •Single-consonant babbling occurs. Increasing interest in sound. 8 to 9 Months •Stringing of vowels and consonants together begins. First few words begin to have meaning (mama, daddy, bye-bye, baby). Begins to understand and obey simple commands such as "Wave bye-bye." 9 to 12 Months •Vocabulary of two or three words. Gestures are used to communicate. Speech development may slow temporarily when walking begins.

TODDLERS: The anterior fontanel closes between ___ and ___

12-18 months of age

INFANTS: The ability to willfully turn from the abdomen to the back occurs at 5 months of age, and the ability to turn from the back to the abdomen occurs at approximately 6 months of age. Infants put to sleep on their sides may easily roll over to a prone (face-down) position, thus placing them at higher risk for

sudden infant death syndrome (SIDS)

INFANTS: Infants do not have the head control to lift their head out of the depression of the object and therefore risk possible

suffocation in the prone position early in infancy (SIDs)

INFANTS: It is important to place infants in a ___________ position for sleep

supine

INFANT: Locomotion

4 to 6 months of age have increasing coordination in their arms. Initial locomotion results in infants propelling themselves backward by pushing with the arms. By 6 to 7 months of age, they are able to bear all their weight on their legs with assistance. Crawling (propelling forward with the belly on the floor) progresses to creeping (on hands and knees with belly off the floor) by 9 months. At this time, they stand while holding on to furniture and can pull themselves to the standing position, but they are unable to maneuver back down except by falling. By 11 months of age, they walk while holding onto furniture or with both hands held, and by 1 year of age, they may be able to walk with one hand held.

INFANTS: the parachute reflex, a protective response to falling, appears at approximately

7 months of age. *Parachute reflex. Infant extends arms to protect from falling.

INFANTS: By 4 months of age, infants can lift the head and front portion of the chest approximately

90 degrees above the table, bearing their weight on the forearms

INFANTS: The pincer grasp is when...& occurs at what age?

the child uses the index and thumb to grasp objects at 8-9 months and progresses to a neat pincer grasp by 10 months

INFANTS: By 5 months, infants are able to

voluntarily grasp an object

INFANTS: 4 to 6 months of age, head control is

well established

INFANTS: Gross Motor Development

•Head control: able to lift head after 1 month •Rolling over: 5 months (abd. - back), 6 months (back - abd.) •Sitting unsupported: age 7 months •Move prone to sitting position: age 10 months

INFANT: Dental Health

•Health education should begin prenatally • Maternal dental health (kissing can transfer infection) •Cleaning: begins when primary teeth erupt (baby tooth brush, warm washcloth) •Dental carries are contagious •Fluoride at 6 months to prevent cavities •Prevention of dental caries •Established dental home by 1 year old NO bottle propping, milk in bed, fruit juices (all contribute to dental decay)

INFANTS: PIAGET: Sensorimotor phase

BIRTH - 12 MONTHS •Imitation: Children progress from reflex activity through simple repetitive behaviors to imitative behavior. By the second half of the year, infants can imitate sounds and simple gestures •Play: They develop a sense of cause and effect as they direct behavior toward objects. Problem solving is primarily by trial and error. •Mental representation: They display a high level of curiosity, experimentation, and enjoyment of novelty and begin to develop a sense of self as they are able to differentiate themselves from their environment •Object permanence: They become aware that objects have permanence—that an object exists even though it is no longer visible. Toward the end of the sensorimotor period, children begin to use language and representational thought. Affect (the outward manifestation of emotion and feeling) is seen as infants begin to develop a sense of permanency. During the first 6 months, infants believe that an object exists only for as long as they can visually perceive it. In other words, out of sight, out of mind. Affect to external objects is evident when the object continues to be present or remembered even though it is beyond the range of perception. Object permanence is a critical component of parent-child attachment and is seen in the development of separation anxiety at 6 to 8 months of age. Sensorimotor phase: Three crucial events take place during this phase. -->The first event involves separation, in which infants learn to separate themselves from other objects in the environment. They realize that others besides themselves control the environment and that certain readjustments must take place for mutual satisfaction to occur. This coincides with Erikson's concept of the formation of trust. -->The second major accomplishment is achieving the concept of object permanence, or the realization that objects that leave the visual field still exist. A typical example of the development of object permanence is when infants are able to pursue objects they observe being hidden under a pillow or behind a chair. This skill develops at approximately 9 to 10 months of age, which corresponds to the time of increased locomotion skills. -->The last major intellectual achievement of this period is the ability to use symbols, or mental representation. The use of symbols allows the infant to think of an object or situation without actually experiencing it. The recognition of symbols is the beginning of the understanding of time and space.

INFANTS: ERICKSON: Trust vs. Mistrust (birth - 1 year)

Based on Freud's "oral" stage Trust vs. mistrust --mothering is essential during the first year in order to build trust. The result of an infant gaining trust is faith and optimism PHASE 1 (BIRTH - 1 YEAR) -The trust that develops is a trust of self, of others, and of the world. Infants "trust" that their feeding, comfort, stimulation, and caring needs will be met -3-4 months, food intake is the most important social activity in which infants engage - Primary narcissism (total concern for oneself) is at its height. However, as bodily processes such as vision, motor movements, and vocalization become better controlled, infants use more advanced behaviors to interact with others. For example, rather than cry, infants may put their arms up to signify a desire to be held. -Grasping has powerful meaning - The reciprocal response to the infant's grasping is the parents' holding on and touching SECOND STAGE -The more active and aggressive modality of biting occurs. Infants learn that they can hold onto what is their own and can more fully control their environment. During this stage, infants may be confronted with one of their first conflicts. If they are breastfeeding, they quickly learn that biting causes the mother to become upset and withdraw the breast. Yet biting also brings internal relief from teething discomfort and a sense of power or control. This conflict may be solved in a variety of ways. The mother may wean the infant from the breast and begin bottle-feeding, or the infant may learn to bite substitute "nipples," such as a pacifier, and retain pleasurable breastfeeding. The successful resolution of this conflict strengthens the mother-child relationship because it occurs at a time when infants are recognizing the mother as the most significant person in their life. Things that lead to mistrust: -Delayed gratification (too much/too little frustration) -The provision of food, warmth, and shelter by itself is inadequate for the development of a strong sense of self. -The infant and parent must jointly learn to satisfactorily meet their needs in order for mutual regulation of frustration to occur. When this synchrony fails to develop, mistrust is the eventual outcome.

TODDLERS: *Piaget*

Characteristics of Preoperational Thought -Preoperational thinking implies that children cannot think in terms of operations (i.e., the ability to manipulate objects in relation to one another in a logical fashion). Rather toddlers think primarily on the basis of their perception of an event. Problem solving is based on what they see or hear directly rather than on what they recall about objects and events Egocentrism: Inability to envision situations from perspectives other than one's own Example: If a person is positioned between the toddler and another child, the toddler, who is facing the person, will explain that both children can see the middle person's face. The young child is unable to realize that the other person views the middle person from a different perspective, the back. Implication: Avoid moralizing about "why" something is wrong if it requires an understanding of someone else's feelings or opinion. Telling a child to stop hitting because hitting hurts the other person is often ineffective because to the aggressor it feels good to hit someone else. Instead emphasize that hitting is not allowed. Transductive reasoning: Reasoning from the particular to the particular Example: Child refuses to eat a food because something previously eaten did not taste good. Implication: Accept child's reasoning; offer refused food at a different time. Global organization: Reasoning that changing any one part of the whole changes the entire whole Example: Child refuses to sleep in room because location of bed is changed. Implication: Accept child's reasoning; use same bed position or introduce change slowly. Centration: Focusing on one aspect rather than considering all possible alternatives Example: Child refuses to eat a food because of its color, even though its taste and smell are acceptable. Implication: Accept child's reasoning. Animism: Attributing lifelike qualities to inanimate objects Example: Child scolds stairs for making child fall down. Implication: Join child in the "scolding." Keep frightening objects out of view. Irreversibility: Inability to undo or reverse actions initiated physically Example: When told to stop doing something such as talking, child is unable to think of positive activity. Implication: State requests or instructions positively (e.g., "Be quiet.") Magical thinking: Believing that thoughts are all-powerful and can cause events Examples: Child wishes someone died; then if the person dies, child feels at fault because of the "bad" thought that made the death happen. • Calling children "bad" because they did something wrong makes them feel as if they are bad. Implications: Clarify that thoughts do not make things happen and that the child is not responsible. • Use "I" rather than "you" messages to communicate thoughts, feelings, expectations, or beliefs without imposing blame or criticism. Emphasize that the act is bad, not the child. Inability to conserve: Inability to understand the idea that a mass can be changed in size, shape, volume, or length without losing or adding to the original mass (instead children judge what they see by the immediate perceptual clues given to them) Example: If two lines of equal length are presented in such a way that one appears longer than the other, child will state that one line is longer even if child measures both lines with a ruler or yardstick and finds that each has the same length. Implications: Change the most obvious perceptual clue to reorient child's view of what is seen. For example, give medicine in a small medicine cup rather than a large cup because child will imagine that the large vessel contains more liquid. If child refuses the medicine in the small cup, pour it into a large cup, because the liquid will appear to be less in a tall, wide container. • Give a large, flat cookie rather than a thick, small one, or do the reverse with meat or cheese; child will usually eat larger size of favorite food and smaller size of less favorite food.

INFANTS: Seborrheic dermatitis interventions

Cradle cap may be prevented with adequate scalp hygiene. Frequently, parents omit shampooing the infant's hair for fear of damaging the fontanels. The nurse should discuss how to shampoo the infant's hair and emphasize that the fontanel is similar to skin anywhere else on the body; it does not puncture or tear with mild pressure. When seborrheic lesions are present, direct the treatment at removing the scales or crusts. Education may need to include a demonstration. Shampooing should be done daily with a mild soap or commercial baby shampoo; medicated shampoos are not necessary, but an anti-seborrheic shampoo containing sulfur and salicylic acid may be used. Shampoo is applied to the scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is thoroughly rinsed. A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing.

INFANTS: Controlling Diaper Rash

Keep skin dry.* Use super-absorbent disposable diapers to reduce skin wetness. Change diapers as soon as soiled—especially with stool—whenever possible, preferably once during the night. Expose healthy or only slightly irritated skin to air, not heat, to dry completely. Apply ointment, such as zinc oxide or petrolatum, to protect skin, especially if skin is very red or has moist, open areas. Avoid removing skin barrier cream with each diaper change; remove waste material and reapply skin barrier cream. To completely remove ointment, especially zinc oxide, use mineral oil; do not wash vigorously. Avoid over-washing the skin, especially with perfumed soaps or commercial wipes, which may be irritating. May use a moisturizer or non-soap cleanser, such as cold cream or Cetaphil, to wipe urine from skin. Gently wipe stool from skin using a soft cloth and warm water. Use disposable diaper wipes that are detergent- and alcohol-free.

INFANTS: Diaper Dermatitis

Diaper dermatitis is caused by prolonged and repetitive contact with an irritant (e.g., urine, feces, soaps, detergents, ointments, friction). Although the irritant in the majority of cases is urine and feces, a combination of factors contributes to irritation. Prolonged contact of the skin with diaper wetness produces higher friction, greater abrasion damage, increased transepidermal permeability, and increased microbial counts. The irritant quality of urine is related to an increase in pH from the breakdown of urea in the presence of fecal urease. The increased pH promotes the activity of fecal enzymes, principally the proteases and lipases, which act as irritants. Fecal enzymes also increase the permeability of skin to bile salts, another potential irritant in feces. Other causes are detergents or soaps from inadequately rinsed cloth diapers or the chemicals in disposable wipes. A common misconception about using cornstarch on skin is that it promotes the growth of C. albicans. Neither cornstarch nor talc promotes the growth of fungi under conditions normally found in the diaper area. Cornstarch is more effective in reducing friction and tends to cake less than talc when the skin is wet. On the basis of these properties and its safety in terms of inhalation injury, cornstarch is the preferred product. Talc should not be used.

INFANT: Sitting

For the first 2 to 3 months, the back is uniformly rounded. The convex cervical curve forms at approximately 3 to 4 months of age, when head control is established. The convex lumbar curve appears when the child begins to sit, at about 4 months of age. As the spinal column straightens, infants can be propped in a sitting position. By 7 months of age, infants can sit alone, leaning forward on their hands for support. By 8 months of age, they can sit well while unsupported and begin to explore their surroundings in this position rather than in a lying position. By 10 months of age, they can maneuver from a prone to a sitting position.

INFANTS: Maturation of Systems

Respiratory -The close proximity of the trachea to the bronchi and its branching structures rapidly transmits infectious agents from one anatomic location to another. The short, straight eustachian tube closely communicates with the ear, allowing infection to ascend from the pharynx to the middle ear. In addition, the inability of the immune system to produce immunoglobulin A (IgA) in the mucosal lining provides less protection against infection in infancy than during later childhood. Cardiac -Increased HR -systolic and diastolic BP fluctuate Hemoglobin/anemia -Maternally derived iron stores are present for the first 5 to 6 months and gradually diminish, which also accounts for lowered hemoglobin levels toward the end of the first 6 months. Digestive -The digestive processes are immature at birth. Although term newborn infants have some limitations in digestive function, human milk has properties that partially compensate for decreased digestive enzymatic activity, thus enabling breastfed infants to receive optimal nutrition during the first several months of life. -The immaturity of the digestive processes is evident in the appearance of stools. During infancy, solid foods (e.g., peas, carrots, corn, raisins) are passed incompletely broken down in the feces. An excess quantity of fiber easily disposes infants to loose, bulky stools. During infancy, the stomach enlarges to accommodate a greater volume of food. By the end of the first year, infants are able to tolerate three meals per day and an evening bottle and may have one or two bowel movements daily. Immune System -The immunologic system undergoes numerous changes during the first year. Full-term newborns receive significant amounts of maternal immunoglobulin G (IgG), which, for approximately 3 months, confers immunity against antigens to which their mothers were exposed Dehydration -A shift in the total body fluid occurs. At birth, 78% of the term infant's body weight is water, with a large percentage being extracellular fluid (ECF). As the percentage of body water decreases, so does the amount of ECF—from 44% at term to 20% in adulthood. The high proportion of ECF, which is composed of blood plasma, interstitial fluid, and lymph, predisposes infants to a more rapid loss of total body fluid and, consequently, dehydration. -The immaturity of the renal structures also predisposes infants to dehydration and electrolyte imbalance. Complete maturity of the kidney occurs during the latter half of the second year, when the cuboidal epithelium of the glomeruli becomes flattened. Before this time, the glomeruli's filtration capacity is reduced. Urine is voided frequently and has a low specific gravity Auditory acquity -Auditory acuity is at adult levels during infancy. Visual acuity begins to improve, and binocular fixation is established. Binocularity, or the fixation of two ocular images into one cerebral picture (fusion), begins to develop by 6 weeks of age and should be well established by 4 months of age. Depth perception (stereopsis) begins to develop by 7 to 9 months of age but may not be fully mature until 2 to 3 years of age, thus increasing the infant's and younger toddler's risk for falling

TODDLERS: Maturation of Systems

Respiratory (complication: URI) The internal structures of the ear and throat continue to be short and straight, and the lymphoid tissue of the tonsils and adenoids continues to be large. As a result, otitis media, tonsillitis, and upper respiratory tract infections are common. s/s: The respiratory and heart rates slow, and the blood pressure increases. Respirations continue to be abdominal. Renal The mature functioning of the renal system serves to conserve fluid under times of stress, decreasing the risk of dehydration. Digestive The digestive processes are fairly complete by the beginning of toddlerhood. The acidity of the gastric contents continues to increase and has a protective function because it is capable of destroying many types of bacteria. Stomach capacity increases to allow for the usual schedule of three meals per day. Voluntary control of elimination. With complete myelination of the spinal cord, control of the anal and urethral sphincters is gradually achieved. The physiologic ability to control the sphincters probably occurs somewhere between 18 and 24 months of age. Bladder capacity also increases considerably, and by 14 to 18 months of age the child is able to retain urine for up to 2 hours or longer. Immune systems The defense mechanisms of the skin and blood, particularly phagocytosis, are much more efficient in toddlers than in infants. The production of antibodies is well established. However, many young children have a sudden increase in colds and minor infections when they enter preschool or other group situations such as day care because of their exposure to new pathogens. Sleep/wake diminishing of crying and unexplained fussiness, and the enhanced predictability in mood. Valuable stimulants of early brain development include the various interactions (talking, singing, and playing) between the toddler and caregivers.

INFANTS: Sitting up

Rounded back, arms out supporting themselves laying, supported sitting up, sitting up unassisted

INFANTS: Sleep & Activity

Sleep patterns vary among infants •By ages 3-4 months, nocturnal sleep lasts 9-11 hours •Breastfed infants awake more often •Napping •Infants are naturally active *•Walkers (can't catch themselves if they fall), swings (no more than 10 mins), and playpens (for protection for an hr at most ex: cooking) are NOT necessary except with described considerations*

INFANTS: SIDs

Temperature: Can overheat Positioning: Do not lay child on tummy (esp. after eating) because the anatomical position of trachea and esophagus - ESOPHAGUS MUST BE LOWER THAN TRACHEA; flat on back ONLY while sleeping because sleep is lighter and they awaken more easily Risk Factors: • Smoking • Co-sleeping • sleeping on a couch, use of a pillow in the infant's bed, soft bedding, loose bedding • adult intoxication • prone sleeping • prolonged Q-T interval or other arrhythmias Certain groups of infants are at increased risk for SIDS: • Low birth weight or preterm birth • Low Apgar scores • Recent viral illness • Siblings of two or more SIDS victims • Male gender • Infants of Native American or African-American ethnicity -sleep apnea is not the cause of SIDS Protective factors: • The pacifier should be used when the infant is falling asleep and does not need to be reinserted if it falls out --using a pacifier at naptime and bedtime, using a pacifier only if the infant is breastfeeding successfully, not using a sweetened coating on the pacifier, and avoiding forcing the infant to use the pacifier. • educating families about the risk for prone sleeping position in infants from birth to 6 months of age, the use of appropriate bedding surfaces, the association with maternal smoking, and the dangers of cosleeping on noninfant surfaces with adults or other children

INFANTS: Feeding and Nutrition

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first 6 months of life for all infants. •Factors influencing choice of feeding method •Breast milk provides complete nutrition. •Breastfed infants are less likely to be at risk for overweight or obesity. •Breastfed infants have less risk of dying from sudden infant death syndrome (SIDS). Considerations: Weaning: When to wean off breastmilk (cultural considerations, societal norms, as long as it isn't doing harm) Juices: Not recommended, no more than 4 oz/day Water: kids are ~70% water, enough fluid from breast milk, introduction of whole milk might also include introduction of water into diet No solid food introduction until 6 months + when they can sit up on their own Finger foods: Good Snacks: Higher caloric intake needed in infants Food allergies: Introduce new foods slowly (1/wk), pay attention to medication allergies and vice versa FIRST 6 MONTHS of life: breast milk is best for infant Honey: NEVER Vitamin D: NEEDS, complications with vitamin D deficiency includes rickets SECOND 6 MONTHS •Selection and preparation of solid foods •Introduction of solid foods •Weaning from breast or bottle

INFANTS: Seborrheic dermatitis

chronic, recurrent, inflammatory reaction of the skin that occurs most commonly on the scalp (cradle cap) but may involve the eyelids (blepharitis), external ear canal (otitis externa), nasolabial folds, and inguinal region. The cause is unknown, although it is more common in early infancy, when sebum production is increased. The lesions are characteristically thick, adherent, yellowish, scaly, oily patches that may or may not be mildly pruritic. Unlike atropic dermatitis, seborrheic dermatitis is not associated with a positive family history for allergy. Diagnosis is made primarily by the appearance and the location of the crusts or scales.

Locomotion involves acquiring the ability to...

bear weight, propel forward on all four extremities, stand upright with support, cruise by holding onto furniture, and, finally, walk alone

INFANTS: An infant who displays head lag at 6 months of age should have a ______________ & ______________ evaluation.

developmental & neurologic

INFANTS: An infant who does not pull to a standing position by 11 to 12 months of age should be further evaluated for possible developmental

dysplasia of the hip

INFANTS: By 3 months of age, they are mostly open. By this time, infants demonstrate a desire to grasp an object, but they "grasp" it more with the

eyes than with the hands

INFANTS: A number of infants attempt their first independent steps by their

first birthday

INFANTS: While infants are awake, a prone position (tummy time) is acceptable to enhance achievement of milestones such as...

head control, crawling, creeping, and turning over

INFANTS: By 6 months of age, infants have increased manipulative skill: they...

hold their bottle, grasp their feet and pull them to their mouth, and feed themselves a cracker.

INFANTS: By 3 months of age, infants can

hold their head well beyond the plane of the body.

INFANTS: By 4 months of age, infants regard both a small ball and the hands and then

look from the object to the hands and back again

INFANTS: At 1 month of age, the hands are

predominantly closed

TODDLERS: *Erikson* Psychosocial development

• Differentiation of self from others, particularly the mother • Toleration of separation from parent • Ability to withstand delayed gratification • Control over bodily functions • Acquisition of socially acceptable behavior • Verbal means of communication • Ability to interact with others in a less egocentric manner Negitivism Several characteristics, especially negativism and ritualism, are typical of toddlers in their quest for autonomy. As they attempt to express their will, they often act with negativism, the persistent negative response to requests. The words "no" or "me do" can be the sole vocabulary. Emotions become strongly expressed, usually in rapid mood swings. One minute toddlers can be engrossed in an activity, and the next minute they might be extremely frustrated because they are unable to manipulate a toy or open a door. If scolded for doing something wrong, they can have a temper tantrum and almost instantaneously pull at the parent's legs to be picked up and comforted. Understanding and coping with these swift changes in behavior is often difficult for parents. Many parents find the negativism exasperating and, instead of dealing constructively with it, give in to it, which further threatens children in their search for learning acceptable methods of interacting with others (see the "Temper Tantrums" section later in this chapter). Ritualism the need to maintain sameness and reliability, provides a sense of comfort. Toddlers can venture out with security when they know that familiar people, places, and routines still exist. One can easily understand why any change in the daily routine represents such a threat to these children. Without comfortable rituals, they have little opportunity to exert autonomy *Successful mastery of the task of autonomy necessitates opportunities for self-mastery while withstanding the frustration of necessary limit setting and delayed gratification. Opportunities for self-mastery are present in appropriate play activities, toilet training, the crisis of sibling rivalry, and successful interactions with significant others.

INFANTS: Managing the colicky infant

• Place infant prone over a covered hot-water bottle or heated towel. • Massage infant's abdomen. • Respond immediately to the crying. • Change infant's position frequently; walk with child's face down and with body across parent's arm, with parent's hand under infant's abdomen, applying gentle pressure. • Use a front carrier for transporting infant. • Swaddle infant tightly with a soft, stretchy blanket. • Take infant for car rides or outside for a change in environment. • Use bottles that minimize air swallowing (curved bottle or inner collapsible bag). • Use a commercial device in the crib that stimulates the vibration and sound of a car ride or plays soothing "noise," in utero sounds, or music. • Provide smaller, frequent feedings; burp infant during and after feedings using the shoulder position or sitting upright, and place infant in an upright seat after feedings. • Introduce a pacifier for added sucking. • If household members smoke, avoid smoking near infant; preferably confine smoking activity to outside of home. • If nothing reduces the crying, place infant in crib and allow to cry; periodically hold and comfort child, and put down again. • Maintain a brief diary of the time of day the crying starts; events going on in household; time, amount, and type of last feeding; length of crying; and characteristics of cry. Although this will not stop the crying, it may help the practitioner identify a possible cause.

INFANTS: Second 6 months

• Prepare parents for child's "stranger anxiety." • Encourage parents to allow child to cling to them and avoid long separation from either. • Guide parents concerning discipline because of infant's increasing mobility. • Encourage use of negative voice and eye contact rather than physical punishment as a means of discipline. • Encourage showing most attention when infant is behaving well, rather than when infant is crying. • Teach injury prevention because of child's advancing motor skills and curiosity. • Encourage parents to leave child with suitable caregiver to allow some free time. • Discuss readiness for weaning. • Explore parents' feelings regarding infant's sleep patterns.

INFANTS: First 6 months

• Teach parents car safety with use of federally approved restraint, facing rearward, in the middle of the back seat—not in a front seat with an air bag. • Understand each parent's adjustment to the newborn, especially mother's emotional needs after birth. • Teach care of infant, and help parents understand his or her individual needs and temperament and that the infant expresses wants through crying. • Reassure parents that infant cannot be spoiled by too much attention during the first 4 to 6 months. • Encourage parents to establish a schedule that meets needs of child and themselves. • Help parents understand infant's need for stimulation in environment. • Support parents' pleasure in seeing child's growing friendliness and social response, especially smiling. • Plan anticipatory guidance for safety. • Stress need for childhood immunizations. • Prepare for introduction of solid foods.

INFANTS: Social Development

•Attachment: Really important (kangaroo care) or else attachment disorder may happen (RAD) •Separation anxiety •Stranger fear •Play: sensory-affective/sensory motor, oral •Personality: Temperament

INFANTS: Motor Vehicle Safety

•Automobile crashes constitute the single greatest risk to an infant's life.•Restraining seats are the only practical means of risk reduction.•Infant safety in motor vehicles depends entirely on adults.•Parents must be educated regarding car seat safety. Rear-facing car seat up until age 2 and place in

INFANTS: Immunizations

•Birth •2 months •4 months •6 months •12 months Term neonates are protected from infection by passive immunity from their mothers. •This is effective for 3 months only. •Breastfed infants receive additional immunoglobulins.

INFANTS: Safe Home Environment

•Burn prevention: water <120 degrees •Safe baby furniture: Fall precautions, pulling themselves up furniture and unable to get down, •Preventing falls: Don't use walker •Preventing asphyxiation: Latex balloons will stick to saliva (Mechanical suffocation highest mortality rate in children <1 years old) •Choking hazards: Orally explorative (buttons, batteries, dimes are dangerous), anti-chocking tube is used to drop something down center to see if it falls through, if it does then child is not allowed to have, window blinds cords can also cause asphyxiation •Preventing lead exposure:

INFANTS: Locomotion

•Crawling: ages 6-7 months •Creeping: 9 months •Walking with assistance: 11 months •Walking alone: 1 year

INFANTS: Concerns Related to Normal Growth and Development

•Fear of separation and strangers •Alternative child care arrangements •Setting limits and discipline •Thumb-sucking and use of a pacifier •Teething (teeth come in ~6 months) •Infant shoes • Patterns of crying

INFANTS: Fine motor Development

•Grasping object: ages 2 to 3 months •Transferring object between hands: age 7 months •Pincer grasp: age 10 months •Removing objects from container: age 11 months •Building tower of two blocks: age 1 year