Ch. 29

Examples of expected outcomes include:

Mother states she feels fatigued but able to cope with sleep disturbance from night waking. Parents state five actions they are taking daily to encourage bonding. Father states both he and spouse are adjusting to new role as parents. Parents verbalize appropriate techniques they use to stimulate infant. Infant demonstrates age-appropriate growth and development. Infant exhibits weight, height, and head and chest circumference within usual norms.

cups

Newborns can drink from a cup as long as a parent controls the fluid flow. An infant can independently drink from a cup by age 8 or 10 months.

reflexes

One-month-old infants still have a strong grasp reflex so they hold their hands in fists so tightly that it is difficult to extend their fingers. As the grasp reflex fades, a 2-month-old infant will hold an object for a few minutes before dropping it. The hands are held open, not closed in fists.

7-8 months

Seven-month-old infants can transfer toys from one hand to the other. They hold a first object when a second one is offered. By 8 months, random reaching and ineffective grasping disappear as a result of advanced eye-hand coordination.

tumb opposition

(ability to bring the thumb and fingers together) begins, but the motion is a scooping or raking one, not a picking-up one, and is not very accurate.

first baby tooth

(typically a central incisor) usually erupts at age 6 months, followed by a new one monthly

appearance of the average infant

-follows across midline at 3 month -respiratory rate slows to 20-30 breaths/min by end of year -pincer grasp at 10 month -liver remains immature -legs may appear short and bowed -social smile at 2 month -first tooth at 6 month -HR slow to 100-120 BPM by end of first year -abdomen protuberant -triples wight by 1 year -grows in height by 50% (from 20-30 in)

infancy

1 month to 1 year

fine motor development

Small body movements such as those made with arms and hands.

6-10 months

By 6 months, infants nearly support their full weight when in a standing position. A 7-month-old child bounces with enjoyment in a standing position. Nine-month-olds can stand holding onto a coffee table if they are placed in that position. Ten-month-olds can pull themselves to a standing position by holding onto the side of a playpen or a low table, but they cannot let themselves down again as yet.

lateral incisior lower

10-16 months

HepA

12- or 15-month visit

MMR

12- or 15-month visit

Var

12- or 15-month visit

VAR

12-month visit

first molar upper

13-19 months

first molar lower

14-18 months

cuspid upper

16-22 months

cuspid lower

17-23 months

DTap

2-, 4-, 6-, and 12-15 months

Hib

2-, 4-, 6-, and 12-month visits

PCV

2-, 4-, 6-, and 12-month visits

IPV

2-, 4-, and 6-month visits

RV

2-, 4-, and possibly at 6-month visit depending on manufacturer

A standard schedule for healthcare visits is

2-week, 2-month, 4-month, 6-month, 9-month, and 12-month visits

A child has until about ? months of age to walk and still be within the normal limit, howeve

22

second molar lower

23-31 months

second molar upper

25-33 months

extrusion reflex

3-4 months (food placed on an infant's tongue is thrust forward and out of the mouth) prevents some infants from eating effectively if they are offered solid food this early (not recommended)

head circumference

By the end of the first year, the brain already reaches two thirds of its adult size. Head circumference increases rapidly during the infant period to reflect this rapid brain growth. Some infants' heads appear asymmetric until the second half of the first year, especially if they are always placed on their back to sleep (which they should be), causing the skull bones to flatten in the back.

10 months

A major milestone at 10 months is the ability to bring the thumb and first finger together in a pincer grasp. This enables children to pick up small objects such as crumbs or pieces of cereal from a high chair tray. They use one finger to point to objects. They offer toys to people but then cannot release them.

central inscisor

6-10 months

parachute reaction

6-9 months ventral suspension position. This means that when infants are suddenly lowered toward an examining table, the arms extend as if to protect themselves from falling. Children with cerebral palsy do not demonstrate this response because they flex their extremities too tightly.

central incisior upper

8-12 months

lateral incisor upper

9-13 months

standing position

A newborn stepping reflex can still be demonstrated at 1 month of age. In a standing position, the infant's knees and hips flex rather than support more than momentary weight. At 3 months, infants try to support part of their weight on their feet.6

HepB

Birth, 2-month, and 6- or 12-month visits

4-5 months

By 4 months, infants are very talkative, cooing, babbling, and gurgling when spoken to. They definitely laugh out loud. By 5 months, an infant says some simple vowel sounds (e.g., "goo-goo," "gah-gah").

height

An infant increases in height during the first year by 50%, or grows from the average birth length of 20 in. to about 30 in. (50.8 to 76.2 cm) Infant growth is most apparent in the trunk during the early months. During the second half of the first year, it becomes more apparent as lengthening of the legs occurs. At the end of the first year, the child's legs may still appear disproportionately short, however, and perhaps bowed. For accuracy, measure infants lying supine on a measuring board even if they are beginning to be able to stand

4-5 months

At 4 months, infants are able to support their weight on their legs. They are successful at doing this because the stepping reflex has faded. By 5 months, the tonic neck reflex should be extinguished, and the Moro reflex should be fading.

6 months

At 6 months, infants learn the art of imitating. They may imitate a parent's cough, for example, or say "Oh!" as a way of attracting attention.

body proportion

By the end of the infant period, the lower jaw is definitely prominent and remains that way throughout life. The circumference of the chest is generally less than that of the head at birth by about 2 cm. It is even with the head circumference in some infants as early as 6 months and in most by 12 months. The abdomen remains protuberant until the child has been walking well for some time, generally well into the toddler period. Cervical, thoracic, and lumbar vertebral curves develop as infants hold up their head, sit, and walk. Lengthening of the lower extremities during the last 6 months of infancy readies the child for walking and often is the final growth that changes the appearance from "babylike" to "toddlerlike."

5 months

Five-month-old children can accept objects that are handed to them by grasping with the whole hand. They can reach and pick up objects without the object being offered and often play with their toes as objects. Fisting that persists beyond 5 months suggests a delay in motor development. Unilateral fisting suggests hemiparesis or paralysis on that side.

interviewing the primary caregiver including

Important areas to discuss include nutrition, elimination, growth patterns, and development.

3 months

In response to a nodding, smiling face, or a friendly tone of voice, a 3-month-old infant will squeal with pleasure or laugh out loud. The same as with differentiating a cry, this is an important step in development because it makes a baby even more fun to be with. Parents spend increased time with infants at this age, not just to care for them but because they enjoy watching them smile at attention.

Much of your assessment of an infant and family will focus on basic needs such as sleep, nutrition, and activity and the parents' adjustment to their new role. Examples of nursing diagnoses include:

Ineffective breastfeeding related to maternal fatigue Disturbed sleep pattern (maternal) related to baby's need to nurse every 2 hours Deficient knowledge related to normal infant growth and development Imbalanced nutrition, less than body requirements, related to infant's difficulty sucking Health-seeking behaviors related to adjusting to parenthood Delayed growth and development related to lack of stimulating environment Risk for impaired parenting related to long hospitalization of infant Readiness for enhanced family coping related to increased financial support Social isolation (maternal) related to lack of adequate social support Ineffective role performance related to new responsibilities within the family

language first month

Infants begin to make small, cooing (dovelike) sounds by the end of the first month.

7-9 months

The amount of talking infants do increases still more at 7 months. They can imitate vowel sounds well (e.g., "oh-oh," "ah-ah," "oo-oo"). By 9 months, an infant usually speaks a first word: "da-da" or "ba-ba." Occasionally, a mother may need reassurance that "da-da" for daddy is an easier syllable to pronounce than "ma-ma" for mommy. German mothers report the first word their babies say is "here," which is "da" in German.

liver

The liver of an infant remains immature, possibly causing an inadequate conjugation of drugs (if a drug should be necessary for treatment of illness) and the inefficient formation of carbohydrate, protein, and vitamins for storage

variation

Variation is so much the rule rather than the exception that a 2-month variation from the average during the infant year is considered normal

prone position

When lying on their stomach, newborns can turn their head to move it out of a position where breathing is impaired, but they cannot hold their head raised for an extended time

sitting position

When placed on his or her back and then pulled to a sitting position, a newborn has extreme head lag; this lag is present until about 1 month. In a sitting position, the back appears rounded and an infant demonstrates only momentary head control.

what is needed for growth and care of the infant

Without proper nutrition, a baby will not grow and physically thrive; without proper stimulation and nurturing care by a consistent caregiver, an infant may not develop a healthy interest in life or a feeling of security essential for future development

IIV

Yearly at 6-month or later visit

by 9 months

a child can creep from the prone position. Creeping means the child has the abdomen off the floor and moves one hand and one leg and then the other hand and leg, using the knees on the floor to locomote

gross motor development

ability to accomplish large body movements

cold tolerance

ability to adjust to cold is mature by age 6 months. By this age, an infant can shiver in response to cold (which increases muscle activity and provides warmth) and has developed additional adipose tissue to serve as insulation. The amount of brown fat, which protected the newborn from cold, decreases during the first year as subcutaneous fat increases.

prehensile ability

ability to coordinate hand movements)

11 months

an infant learns to "cruise" or move about the crib or room by holding onto objects such as the crib rails, chairs, walls, and low tables

physiological anemia

at 2 to 3 months of age. This occurs because the life of a typical red cell is 4 months, so the cells the child had at birth begin to disintegrate at that time, yet new cells are not yet being produced in adequate replacement numbers. Hemoglobin in an infant becomes totally converted from fetal to adult hemoglobin at 5 to 6 months of age. Infants may experience a decrease in serum iron levels at 6 to 9 months as the last of iron stores established in utero are used.

immune system

becomes functional by at least 2 months of age; an infant can actively produce both immune globulin (Ig)G and IgM antibodies by 1 year. The levels of other immunoglobulins (IgA, IgE, and IgD) are not plentiful until preschool age, which is the reason why infants continue to need protection from infection

natal teeth

born with teeth

7 months

child can sit alone but only when the hands are held forward for balance. An 8-month-old child can sit securely without any additional support This is a major milestone in development that should always be considered in an assessment. Children with delayed cognitive or motor development may not accomplish this step at this time.

3 month

child lifts the head and shoulders well off the table and looks around when prone. The pelvis is flat on the table, no longer elevated. Some children can turn from a prone to a side-lying position at this age.

by 4 months

child reaches an important milestone by no longer demonstrating head lag when pulled to a sitting position.

flattened skull bones suggest

continue to place the infant on the back to sleep but to spend "tummy time" daily with the infant placed in a prone position to prevent this flattening. This early head distortion will gradually correct itself as the child sleeps less and spends more time with the head in an erect position. Persistence of asymmetry suggests an infant is not receiving enough stimulation or is spending the majority of time lying in bed.

deciduous teeth

essential for allowing proper growth of the dental arch. If they are injured, children need conscientious follow-up to be certain there is space for permanent teeth to erupt effectively or that permanent teeth are not discolored

fluid compartment and shifts

extracellular fluid accounts for approximately 35% of an infant's body weight, with intracellular fluid accounting for approximately 40% by the end of the first year, in contrast to adult proportions of 20% and 40%, respectively. This proportional difference increases an infant's susceptibility to dehydration from illnesses, such as diarrhea, because loss of extracellular fluid could result in loss of over a third of an infant's body fluid.

most babies turn

front to back first and then, 1 month later, back to front. Those with spasticity may turn first back to front.

GI tract

gastrointestinal tract is immature in its ability to digest food and mechanically move it along. These functions mature gradually during the infant year. Although the ability to digest protein is present and effective at birth, the amount of amylase, which is necessary for the digestion of complex carbohydrates, is deficient until approximately the third month. Lipase, necessary for the digestion of saturated fat, is decreased in amount during the entire first year

6 months

grasping has advanced to a point where a child can hold objects in both hands. Infants at this age will drop one toy when a second one is offered, however. They can hold a spoon and start to feed themselves (with much spilling). The Moro, the palmar grasp, and the tonic neck reflexes have completely faded. A Moro reflex that persists beyond this point should arouse suspicion of neurologic disease.

cephalocaudal

head to toe

cardiovascular system

heart rate slows from 110 to 160 beats/min to 100 to 120 beats/min by the end of the first year. The heart continues to occupy a little over half the width of the chest. Pulse rate may slow with inhalation (sinus arrhythmia), but this does not become marked until preschool age. That the heart is becoming more efficient is shown by a decreasing pulse rate and a slightly elevated blood pressure (from an average of 80/40 to 100/60 mmHg).

indications of growth

height, weight, and head circumference are important indicators of growth, so they should be measured and plotted on standard growth charts

4 month old

ift their chests off the bed and look around actively, turning their head from side to side. They are able to turn from front to back. The first time, this tends to occur as an extension of lifting the chest combined with a neck-righting reflex, which begins at this age. This reflex causes babies to lose their balance and roll sideways when lifting the head up. The baby is frightened by the sudden feeling of rolling free and probably cries. After this happens a few more times, however, a baby begins to delight in this new accomplishment.

by 5 months

infant can be seen to straighten his or her back when held or propped in a sitting position.

4 months

infants bring their hands together and pull at their clothes. They will shake a rattle placed in their hand.

10-12 months

infants can generally say two words in addition to "ma-ma" and "da-da," and they use those two words with meaning.

12 months

infants can hold a crayon well enough to draw a semi-straight line. They enjoy putting objects such as small blocks in containers and taking them out again. They can hold a cup and spoon to feed themselves fairly well (if they have been allowed to practice) and can take off socks and push their hands into sleeves (again, if they have been allowed to practice). They can offer toys and release them.

by 2 months

infants can hold their head fairly steady when sitting up, although their head does tend to bob forward and will still show head lag when pulled to a sitting position

By 6 months

infants can raise their chests and the upper part of their abdomens off the table.

by 6 months

infants can sit momentarily without support. They anticipate being picked up and reach up with their hands from this position. Some parents expect a child this age to be able to sit securely and may be worried because their sitting posture is still extremely shaky when it is normal. Infants are capable of movement by hitching or sliding backward from this position. Alert parents that an infant this young is capable of moving from one spot to another in this way so they are prepared for this and can prevent unintentional injuries.

3 months

infants reach for attractive objects in front of them. Their grasp is unpracticed so they usually miss them. You can assure parents this is part of normal development so they do not think their child is nearsighted or farsighted or has poor coordination.

9 months

infants sit so steadily that they can lean forward and regain their balance. They may still lose their balance if they lean sideways, which is a skill not achieved for another month.

weight

most infants double their birth weight by 4 to 6 months and triple it by 1 year. During the first 6 months, infants typically average a weight gain of 2 lb per month. During the second 6 months, weight gain is approximately 1 lb per month. The average 1-year-old boy weighs 10 kg (22 lb); the average girl weighs 9.5 kg (21 lb)

landau reflex

new reflex that develops at 3 months. When held in ventral suspension, the infant's head, legs, and spine extend. When the head is depressed, the hips, knees, and elbows flex. This reflex continues to be present in most infants during the second 6 months of life, but then it becomes increasingly difficult to demonstrate. It is an important reflex to assess because a child with motor weakness, cerebral palsy, or other neuromuscular defects will not be able to demonstrate the reflex.

One of the most important interventions of the infant period is teaching new parents about

normal growth and development milestones

outcomes of infant care

realistic based on the family's new circumstances. Parents of infants, especially first-time parents, must do a lot of adjusting, and this takes time. Try to suggest activities that can be easily incorporated into the family's lifestyle.

Ventral suspension

refers to an infant's appearance when held in midair on a horizontal plane and supported by a hand under the abdomen. In this position, the newborn allows the head to hang down with little effort at control. One-month-old infants lift their head momentarily and then drop it again. Two-month-old infants hold their head in the same plane as the rest of their body, a major advance in muscle control. By 3 months, infants lift and maintain their head well above the plane of the rest of the body in ventral suspension.

kidneys

remain immature and not as efficient at eliminating body wastes as in an adult. The endocrine system remains particularly immature in response to pituitary stimulation, such as adrenocorticotropic hormone, or insulin production from the pancreas. Without these hormones functioning effectively, an infant may not be able to respond to stress as effectively as an adult.

respiratory

respiratory rate of an infant slows from 30 to 60 breaths/min to 20 to 30 breaths/min by the end of the first year. Because the lumens of the respiratory tract remain small and mucus production by the tract to clear invading microorganisms is still inefficient, upper respiratory infections occur readily and tend to be more severe than in adults.

fluoride

should be administered at 6 months of age

neonatal

teeth erupt in the first 4 weeks of life

12 months

the child can stand alone at least momentarily. Some parents expect children to walk at this time and may be disappointed to see their child is merely standing still.

2 months

they can differentiate their cry. For example, parents can begin to distinguish a cry that means "hungry" from one that means "wet" or from one that means "lonely." This is an important milestone in development for an infant; asking if a parent can tell the difference in crying is a good way to assess how far a parent has progressed in the task of parenting

1 month

they lift their head and turn it easily to the side. They still tend to keep their knees tucked under their abdomen, however, as they did as a newborn. Two-month-old infants can raise their head and maintain the position, but they cannot raise their chest high enough to look around yet. Their head is still held facing downward.

what occurs to weight and height during infancy

triples birth weight and increases length by 50%

loosely attached supernumerary or extra teeth

usually removed before they loosen spontaneously and are aspirated by the infant. In most infants, natal or neonatal teeth are deciduous or are fixed firmly. These should not be removed because no other teeth will grow to replace them until the permanent teeth erupt at age 6 or 7 years.

4 positions used to assess gross motor development

ventral suspension, prone, sitting, and standing

both parents work during the day

you might suggest the parents ask their child's caretaker to talk to their infant more. Encourage parents to spend additional time each evening reading or reciting nursery rhymes to their baby. Working together, these combined actions should increase the baby's language skills.