M/C Exam 1: Ped Growth & Development

Toddler Temperament

"Difficult" or "Easy" - choose your battles *Temper tantrums*: Kicking, screaming, holding breath if not hurting self, ignore them Need consistent, age appropriate expectations Discipline: *Mild - stern voice, sustained eye contact* More structured: time out, physical containment, rewards *Give comfort*, don't give in to requests Time out- *1 minute per each year of age*- non stimulating environment

Toddler Psychosocial Development

(ERIKSON) *Autonomy vs Shame & Doubt* *Independence* *Negativism (negative responses)* *Ritualism* Transitional objects *Animism* Moral development: *Egocentric* - see own perspective *Punishment and obedience orientation* *Gender identity by age 3* Centration- focusing on only one part of the situation Egocentric

Box 31-1 Injury Prevention

ATI pg 27-28

Infant: Promoting Optimal Growth & Development

Biologic development Proportional changes: WEIGHT 5- to 7-oz weight gain/week 1st 5 MONTHS: gain 1.5 lbs/month 2 WKS: regain birth weight (up to 10% loss) <<<<*6 MONTHS: double birth weight* *1 YEAR: triple birth weight* >>>>>> HEIGHT 6 MONTHS: gain 1 inch/month for 6 months 1 YEAR: gain 0.5 inch/month Average at birth: 48-53 cm (19-21 inches) 50% increase in height by 1 year know conversions *Growth in "spurts"* rather than gradual pattern *Development of skills progress with physical development* so infants can respond to and cope with their environment. MATURATION: slowing HR and RR increased BP physiologic anemia 3-6 mo enzymes for milk until 5-6 mo Table 31-1 GROWTH AND DEVELOPMENT DURING INFANCY 1 Month: PHYSICAL: Weight gain of 150-200 g (5-7 oz) weekly for first 6 mo Height gain of 2.5 cm (1 inch) monthly for first 6 mo Head circumference increases by 1.5 cm (inch) monthly for first 6 mo Primitive reflexes present and strong Doll's eye reflexes and dance reflex fading Obligatory nose breathing (most infants) *Head increases by 33% by 1 year* GROSS MOTOR: Assumes flexed position with pelvis high but knees not under abdomen when prone (at birth, knees flexed under abdomen)* Can turn head from side to side when prone; lifts head momentarily from bed (see Fig. 31-3, A)* Has marked head lag, especially when pulled from lying to sitting position (see Fig. 31-2, A) Holds head momentarily parallel and in midline when suspended in prone position Assumes asymmetric tonic neck reflex position when supine When held in standing position, body is limp at knees and hips In sitting position, back is uniformly rounded, absence of head control FINE MOTOR: Hands predominantly closed Grasp reflex strong Hand clenches on contact with rattle SENSORY: Able to fixate on moving object in range of 45 degrees when held at a distance of 20-25 cm (8-10 inches) Visual acuity approaches 20/100† Follows light to midline Quiets when hears a voice VOCALIZATION: Cries to express displeasure Makes small, throaty sounds Makes comfort sounds during feeding SOCIALIZATION/COGNITION: Is in sensorimotor phase—stage I, use of reflexes (birth-1 mo), and stage II, primary circular reactions (1-4 mo) Watches parent's face intently as parent talks to infant 2 Months: PHYSICAL: Posterior fontanel closed Crawling reflex disappears GROSS MOTOR: Assumes less flexed position when prone—hips flat, legs extended, arms flexed, head to side* Less head lag when pulled to sitting position (see Fig. 31-2, B) Can maintain head in same plane as rest of body when held in ventral suspension When prone, can lift head almost 45 degrees off table When moved to sitting position, head is held up but bends forward (see Fig. 31-5, B) Assumes asymmetric tonic neck reflex position intermittently FINE MOTOR: Hands often open Grasp reflex fading SENSORY: Binocular fixation and convergence to near objects beginning When supine, follows dangling toy from side to point beyond midline Visually searches to locate sounds Turns head to side when sound is made at level of ear VOCALIZATION: Vocalizes, distinct from crying* Crying becomes differentiated Coos Vocalizes to familiar voice SOCIALIZATION/COGNITION: Demonstrates social smile in response to various stimuli 3 Months: PHYSICAL Primitive reflexes fading Able to hold head more erect when sitting, but still bobs forward Has only slight head lag when pulled to sitting position Assumes symmetric body positioning GROSS MOTOR: Able to raise head and shoulders from prone position to a 45- to 90-degree angle from table; bears weight on forearms When held in standing position, able to bear slight fraction of weight on legs Regards own hand FINE MOTOR Actively holds rattle but will not reach for it* Grasp reflex absent Hands kept loosely open Clutches own hand; pulls at blankets and clothes SENSORY Follows object to periphery (180 degrees)* Locates sound by turning head to side and looking in same direction* Begins to have ability to coordinate stimuli from various sense organs VOCALIZATION Squeals aloud to show pleasure* Coos, babbles, chuckles Vocalizes when smiling "Talks" a great deal when spoken to Less crying during periods of wakefulness SOCIALIZATION/COGNITION Displays considerable interest in surrounding Ceases crying when parent enters room Can recognize familiar faces and objects, such as feeding bottle Shows awareness of strange situations 4 Months PHYSICAL: Drooling begins Moro, tonic neck, and rooting reflexes have disappeared* GROSS MOTOR Has almost no head lag when pulled to sitting position (see Fig. 31-2, C)* Balances head well in sitting position (see Fig. 31-5, C)* Back less rounded, curved only in lumbar area Able to sit erect if propped up Able to raise head and chest off surface to angle of 90 degrees (see Fig. 31-3, B) Assumes predominant symmetric position Rolls from back to side* FINE MOTOR Inspects and plays with hands; pulls clothing or blanket over face in play* Tries to reach objects with hand but overshoots Grasps object with both hands Plays with rattle placed in hand, shakes it, but cannot pick it up if dropped Can carry objects to mouth SENSORY Able to accommodate to near objects Binocular vision fairly well established Can focus on a 1.25 cm (½-inch) block Beginning eye-hand coordination VOCALIZATION Makes consonant sounds n, k, g, p, b Laughs aloud* Vocalization changes according to mood SOCIALIZAITON/COGNITION Is in stage III, secondary circular reactions Demands attention by fussing; becomes bored if left alone Enjoys social interaction with people Anticipates feeding when sees bottle or mother if breastfeeding Shows excitement with whole body, squeals, breathes heavily Shows interest in strange stimuli Begins to show memory 5 Months PHYSICAL Beginning signs of tooth eruption as bumps on gums are palpable Birth weight doubles GROSS MOTOR No head lag when pulled to sitting position When sitting, able to hold head erect and steady Able to sit for longer periods when back is well supported Back straight When prone, assumes symmetric positioning with arms extended Can turn over from abdomen to back* When supine, puts feet to mouth FINE MOTOR Able to grasp objects voluntarily* Uses palmar grasp, bidextrous approach Plays with toes Takes objects directly to mouth Holds one cube while regarding a second one SENSORY Visually pursues a dropped object Is able to sustain visual inspection of an object Can localize sounds made below ear VOCALIZATION Squeals Makes cooing vowel sounds interspersed with consonant sounds (e.g., ah-goo) SOCIALIZATION/COGNITION Smiles at mirror image Pats bottle or breast with both hands More enthusiastically playful, but may have rapid mood swings Is able to discriminate strangers from family Vocalizes displeasure when object is taken away Discovers parts of body 6 Months PHYSICAL Growth rate may begin to decline Weight gain of 90-150 g (3-5 oz) weekly for next 6 mo Height gain of 1.25 cm (0.5 inch) monthly for next 6 mo Teething may begin with eruption of two lower central incisors* Chewing and biting occur* GROSS MOTOR When prone, can lift chest and upper abdomen off surface, bearing weight on hands (see Fig. 31-3, C) When about to be pulled to a sitting position, lifts head Sits in high chair with back straight Rolls from back to abdomen When held in standing position, bears almost all of weight Hand regard absent FINE MOTOR Resecures a dropped object Drops one cube when another is given Grasps and manipulates small objects Holds bottle Grasps feet and pulls to mouth SENSORY Adjusts posture to see an object Prefers more complex visual stimuli Can localize sounds made above ear Will turn head to the side, then look up or down VOCALIZATION Begins to imitate sounds* Babbling resembles one-syllable utterances—ma, mu, da, di, hi* Vocalizes to toys, mirror image Takes pleasure in hearing own sounds (self-reinforcement) SOCIAL/COGNITIVE Recognizes parents; begins to fear strangers Holds arms out to be picked up Has definite likes and dislikes Begins to imitate (cough, protrusion of tongue) Excites on hearing footsteps Laughs when head is hidden in a towel Briefly searches for a dropped object (object permanence beginning)* Frequent mood swings—from crying to laughing with little or no provocation 7 Months PHYSICAL Sits alone without support GROSS MOTOR When supine, spontaneously lifts head off surface Sits, leaning forward on hands (see Fig. 31-5, D)* When prone, bears weight on one hand Sits erect momentarily Bears full weight on feet (see Fig. 31-6, A) When held in standing position, bounces actively FINE MOTOR Transfers objects from one hand to the other (see Fig. 31-5, E)* Has unidextrous approach and grasp Holds two cubes more than momentarily Bangs cube on table Rakes at a small object SENSORY Can fixate on very small objects* Responds to own name Localizes sound by turning head in a curving arch Beginning awareness of depth and space Has taste preferences VOCAL Produces vowel sounds and chained syllables—baba, dada, kaka* Vocalizes four distinct vowel sounds "Talks" when others are talking SOCIAL/COGNITIVE Increasing fear of strangers; shows signs of fretfulness when parent disappears* Imitates simple acts and noises Tries to attract attention by coughing or snorting Plays peekaboo Demonstrates dislike of food by keeping lips closed Exhibits oral aggressiveness in biting and mouthing Demonstrates expectation in response to repetition of stimuli 8 Months PHYSICAL Begins to show regular patterns in bladder and bowel elimination Parachute reflex appears (see Fig. 31-4) Eruption of upper central incisors GROSS MOTOR Sits steadily unsupported (see Fig. 31-5, E)* Readily bears weight on legs when supported; may stand holding onto furniture Adjusts posture to reach an object FINE MOTOR Has beginning pincer grasp using index, fourth, and fifth fingers against lower part of thumb Releases objects at will Rings bell purposely Retains two cubes while regarding third cube Secures an object by pulling on a string Reaches persistently for toys out of reach VOCAL Makes consonant sounds t, d, w Listens selectively to familiar words Utterances signal emphasis and emotion Combines syllables, such as dada, but does not ascribe meaning to them SOCIAL/COGNITIVE Increasing anxiety over loss of parent, particularly mother, and fear of strangers Responds to word "no" Dislikes dressing, undressing, and diaper change 9 Months PHYSICAL Eruption of upper lateral incisor may begin GROSS MOTOR Creeps on hands and knees Sits steadily on floor for prolonged time (10 min) Recovers balance when leaning forward but cannot do so when leaning sideways Pulls self to standing position and stands holding onto furniture (see Fig. 31-6, B and C)* FINE MOTOR Uses thumb and index fingers in crude pincer grasp (see Fig. 31-1)* Preference for use of dominant hand now evident Grasps third cube Compares two cubes by bringing them together SENSORY Localizes sounds by turning head diagonally and directly toward sound Depth perception increasing VOCAL Responds to simple verbal commands Comprehends "no-no" SOCIAL/COGNITIVE Parent (mother) is increasingly important for own sake Shows increasing interest in pleasing parent Begins to show fears of going to bed and being left alone Puts arms in front of face to avoid having it washed 10 Months PHYSICAL Labyrinth-righting reflex is strongest—when infant is in prone or supine position, is able to raise head GROSS MOTOR Can change from prone to sitting position Stands while holding onto furniture, sits by falling down Recovers balance easily while sitting While standing, lifts one foot to take a step (see Fig. 31-6, D) FINE MOTOR Crude release of an object beginning Grasps bell by handle VOCAL Says "dada," "mama" with meaning* Comprehends "bye-bye" May say one word (e.g., "hi," "bye," "no") SOCIAL/COGNITIVE Inhibits behavior to verbal command of "no-no" or own name Imitates facial expressions; waves bye-bye Extends toy to another person but will not release it Develops object permanence* Repeats actions that attract attention and cause laughter Pulls clothes of another to attract attention Plays interactive game such as pat-a-cake Reacts to adult anger; cries when scolded Demonstrates independence in dressing, feeding, locomotive skills, and testing of parents Looks at and follows pictures in a book 11 Months PHYSICAL Eruption of lower lateral incisor may begin GROSS MOTOR When sitting, pivots to reach toward back to pick up an object Cruises or walks holding onto furniture or with both hands held* FINE MOTOR Explores objects more thoroughly (e.g., clapper inside bell) Has neat pincer grasp Drops object deliberately for it to be picked up Puts one object after another into a container (sequential play) Able to manipulate an object to remove it from tight-fitting enclosure VOCAL Imitates definite speech sounds SOCIAL/COGNITIVE Experiences joy and satisfaction when a task is mastered Reacts to restrictions with frustration Rolls ball to another on request Anticipates body gestures when a familiar nursery rhyme or story is being told (e.g., holds toes and feet in response to "This little piggy went to market") Plays game up-down, "so big," or peekaboo Shakes head for "no" 12 months PHYSICAL Birth weight tripled* Birth length increased by 50%* Head and chest circumference equal (head circumference 46 cm [18 inches]) Has total of six to eight deciduous teeth Anterior fontanel almost closed Landau reflex fading Babinski reflex disappears Lumbar curve develops; lordosis evident during walking GROSS MOTOR Walks with one hand held* Cruises well May attempt to stand alone momentarily; may attempt first step alone* Can sit down from standing position without help FINE MOTOR Releases cube in cup Attempts to build two-block tower but fails Tries to insert a pellet into a narrow-necked bottle but fails Can turn pages in a book, many at a time SENSORY Discriminates simple geometric forms (e.g., circle) Amblyopia may develop with lack of binocularity Can follow rapidly moving object Controls and adjusts response to sound; listens for sound to recur VOCAL Says three to five words besides "dada," "mama"* Comprehends meaning of several words (comprehension always precedes verbalization) Recognizes objects by name Imitates animal sounds Understands simple verbal commands (e.g., "Give it to me," "Show me your eyes") SOCIAL/COGNITIVE Shows emotions such as jealousy, affection (may give hug or kiss on request), anger, fear Enjoys familiar surroundings and explores away from parent Is fearful in strange situation; clings to parent May develop habit of "security blanket" or favorite toy Has increasing determination to practice locomotor skills Searches for an object even if it has not been hidden, but searches only where object was last seen*

Adolescence 12-20 years

GROWTH Final 20-25% of height attained during puberty *Girls stop growing 2-2.5 years after menarche, grow 2-8 inches* 2-6 mo after menarche Girls gain 7-25 kg (15 - 55 pounds) Boys stop growing at age 18-20 years, grow 4-12 inches Boys gain 7-30 kg (15.5-66 pounds) SEXUAL MATURATION - FEMALES <<<<*Appearance of breast buds (thelarche)*>>>> Caucasian- average 10 yr (range 8-12.75 yr) African-American- average 9 yr (range 7-11 years) 10.5-15 years average menarche age Growth of pubic hair: Follows breast bud development in 2-6 months Axillary hair growth Onset of menstruation (menarche): Caucasian- average 12.5 years African-American- average 12 years Normal age range 10.5-15.5 years 1st signs of puberty for male and females *TANNER STAGING* - FEMALES SEXUAL MATURATION - MALES <<<<*Testicular enlargement (thelarche)*>>>> Appearance of pubic hair Growth of genitalia Growth of axillary hair Facial hair growth Change in voice *TANNER STAGING* - MALES COGNITIVE Piaget: *formal operations* Able to think through more than 2 variables concurrently Think abstractly and deal with principles *Evaluate own thinking* *abstract* Imaginative and idealistic Improved attention span Capable of using formal logic to make decisions Able to understand how actions influence others Think about future- college, occupational opportunities PSYCHOSOCIAL Erikson: *Identity vs Role Confusion* Personal sense of identity *Group identity with peer group* Increased interest in romantic relationships Develop sexual identity *View themselves as invincible* Solidify work habits and plan for careers *Have best friends - same sex* Parent-child relationships allow greater independence *Body image* In the early phases being part of a group and peer pressure is intense. As it progresses they are developing a sense of self. AGE APPROPRIATE ACTIVITIES Non-violent video games Social Media Non-violent music Sports Caring for a pet Career training programs Reading Social events- dances, movies, football games NUTRITION Rapid growth and metabolism- need high quality foods May omit meals *Common deficiencies*: Iron, Ca, Vitamins Excess in sugar, fat, cholesterol, and sodium Anorexia and bulimia more common Obesity, hyperlipidemia and hypertension common *Screening Hct/Hgb in females* for anemia Encourage physical activity *Body Image!* HEALTH PROMOTION IN SCHOOLS School based health education Promotion of physical education Tobacco free policies *Responsible sexual behavior* School based clinics Provide an atmosphere where adolescents can be comfortable asking questions BODILY HARM Injuries cause 70% of teen deaths *MVA, homicide, suicide* Firearms locked Helmet use with bikes, skateboards, and snowboards- adolescents more noncompliant Use proper sports protection Body art safety *Discourage tanning- suggest lotions* Be aware of changes in mood. *Monitor for self-harm*: Poor school performance Lack of interest Social isolation Sleep or appetite disturbances Expression of suicidal thoughts- *Warning Signs* Box 35-8 • Preoccupation with themes of death—focuses on morbid thoughts • Wants to give away cherished possessions • Talks of own death, desire to die • Loss of energy, loss of interest, listlessness • Exhaustion without obvious cause • Changes in sleep patterns—too much or too little • Increased irritability, argumentativeness, or stubbornness • Physical complaints—recurrent stomachaches, headaches • Repeated visits to physician, nurse practitioner, or emergency department for treatment of injuries • Reckless behavior • Antisocial behavior—engages in drinking, uses drugs, fights, commits acts of vandalism, runs away from home, becomes sexually promiscuous • Sudden change in school performance—lowered grades, cutting classes, dropping out of activities • Resists or refuses to go to school • Remains distant, sad, remote—flat affect, frozen facial expression • Describes self as worthless • Sudden cheerfulness after deep depression • Social withdrawal from friends, activities, interests that were previously enjoyed • Impaired concentration • Dramatic change in appetite Do not ignore any threat of suicide. *Parasuicide is any behavior in the range of contemplating suicide*. SEXUALITY Role of parents, schools, churches, nurses, and social organizations Teen pregnancy Multiple sex partners and STI Gay, lesbian, transgender and bisexual teens Ask in nonjudgmental way Emphasize abstinence and safe sex *Address questions in "matter of fact" way using proper terminology* Protect adolescents to access of unrealistic expectations through media devices SAFETY undue risk taken *#1 COD for adolescent: MVA* *#2 homicide* *listen for parasuicide* SUBSTANCE ABUSE Challenge authority, demonstrate autonomy, fit in with peers, or deal with stress *Monitor for s/s of substance abuse* Teach adolescent to "Say No" "No tolerance" attitude Substance abuse for adolescence includes alcohol, marijuana , narcotics, CNS stimulants, hydrocarbons, fluorocarbons, and mind altering drugs. *MOTOR VEHICLE SAFETY* Drivers education courses and practice with parent Seat belt use *Discourage cell phone use* Don't use alcohol or drugs and drive Helmets with bikes, skateboards *Role model appropriate behavior* IMMUNIZATIONS 16-18 years Meningococcal vaccine booster Need before college Annual flu vaccine: injection or nasal spray 12 grade shots

Toddler Nutrition

Physiologic anorexia - *poor appetite* *Finger foods - "Grazing"* Regular meal times and healthy snacks *Serving size 1 Tbs/year of age* *Milk- 24-30 oz/day, can switch from whole milk to low fat at age 2 years* *Limit juice to 4-6 oz/day* *Keep iron in diet (meats, green vegetables)* Picky eaters, Unpredictable table manners- use plastic Aware of pleasure of eating and control of refusing food DENTITION See Dentist *within 6 month of first teeth*. Begin using *pea-sized amount of tooth paste at age 2*. *Avoid sugar snacks and bedtime bottles*. Parents should brush their teeth.

Infant Nutrition

*Breastfeeding exclusively first 6 months* and continue A critical health decision Evidence that breastfeeding provides protective effect against infant and childhood infections, allergies, asthma, inflammatory bowel disease, Necrotizing Enterocolitis, sepsis, and sudden infant death syndrome (SIDS). As well as sustained protective effects against diabetes, cancer, and improved neurodevelopmental outcomes *All preterm infants should receive human milk as primary diet*: Mom's own milk - From breast, or pumped Donor milk - Milk Bank (HMBANA) FORMULA SAFETY: *iron-fortified milk* dilute properly - too much water - hyponatremia - seizures get warm water out of sink The American Academy of Pediatrics supports the recommendation for *exclusive breastfeeding for about 6 months, followed by introduction of complementary foods, with continued breastfeeding through 12 months or as long as mutually desired by mother and baby*. There is a conceptual change in that the decision to breastfeed is not a lifestyle choice but rather a basic and critical health decision regarding infant welfare. This conclusion is based on the evidence that breastfeeding provides a protective effect against infant and childhood infections, allergies, inflammatory bowel disease, and sudden infant death syndrome (SIDS). http://pediatrics.aappublications.org/content/129/3/e827 http://www2.aap.org/breastfeeding/files/pdf/Spring2012Newsletter.pdf 12 months - screening test - Hgb (fingerprick) Photo: http://www.shelbycountybreastfeeding.org/ NUTRITION/DENTITION Breast feeding exclusively first 6 months and continue *Alternative Fe fortified formula for 1st year*. Proper dilution is key for formulas Do not microwave Supplements: *Fluoride 0.25 mg daily*, if drinking water deficient in fluoride - *after 6 months* *Iron - screen Hgb at 12 months* *Vitamin D* - given at birth to prevent Rickets *Food introduction after turning 6 months-one new a week-spoon feed* *Rice Cereal- Vegetables-Fruits-Meats*- Continue Breastfeeding or Infant Formula *Foods to avoid early- cow's milk, honey, citrus, strawberries, apple juice, eggs * *White grape juice* is allowed, only *4-6 oz / day* maximum Weaning- gradual, replace one feeding at a time. Nighttime bottle wean last. Teeth brushing-using water or less than pea size of toothpaste until 2 years *Avoid- bottle propping, milk in bed, and fruit juices* 12 months - screening test - Hbg (fingerprick) brush teeth with water no milk in bed no cow's milk, honey , citrus, strawberries, apple juice, or eggs till older white grape juice okay

Age Appropriate Activities - Toddler

*Parallel Play* - independent play side by side Blocks Books Push/pull toys Balls Large piece puzzles Finger paints/thick crayons Imagination: Boxes, kitchen pots/spoons Play is the universal language and key for development . Children communicate through play. Enables coping and supports creativity, releases stress

Piaget - Infant Cognitive

*Sensorimotor period* 1. Reflexes- *Primitive* - grasping a rattle by reflex 2. Voluntary Acts- reaching and grasping for a wanted toy 3. Imitation of sounds and gestures (play) 4. Apply to a new situation -drop the toy, someone will pick it up Affects - Wave "bye bye" mom goes to work *Object permanence*: 6 MONTHS - some object permanence 8-12 MONTHS Advanced object permanence, separation anxiety 8 MONTHS - Baby laughing https://www.youtube.com/watch?v=RP4abiHdQpc

Toddler Toilet Training

*Voluntary sphincter control begins 18-24 months* *Train at 22-30 months* Begin when child feels urge to urinate or defecate and can stay dry 2 hours Nighttime develops last - should master before 6 years Easy to manage clothing, pull up diapers *Limit practice sessions to 5-8 minutes* *Stay with child, give clear directions, rewards NOT a punishment* Use patience and *consistency*

Toddler Immunizations

12-15 months: IPV, Hib, PCV, MMR and Varicella 12-23 months: HAV 2 doses at least 6 months apart 15-18 months: DTaP 12-36 months: annual influenza Can get live nasal spray after 2 years of age

Toddler Fine Motor

15 months Uses a cup well Builds a tower of 2 blocks 18 months Manages a spoon Turns pages in book 2-3 at a time Throws ball overhand 2 years Builds a tower of 6-7 blocks 2.5 years Draws circles Has good hand-finger coordination

Toddler Gross Motor

15 months Walks without help Creeps up stairs 18 months Assumes a standing position 2 years <<<<Walks up and down stairs>>>>> 2.5 years Jumps in place with both feet Stands on one foot momentarily top heavy distribution safety issue - stairs, speed

Toddler Safety

2nd highest rate for deaths from accidents Less restricted in their environment Unaware of danger Aspiration and Suffocation- Same precautions as infants Bodily Harm- Same precautions as infants + Store sharp items, firearms, monitor for animals and strangers Drowning- Same precautions as infants+ *teach to swim* Burns- Same precautions as infants Poisonings- Same precautions as infants+by age 2 yo, children can climb and open most lids, safety locks for cabinets MOTOR VEHICLE SAFETY Approved car seats in back, away from air bags. Air bags off if in the front. *Rear facing car seats until 2 years or recommended weight* *Convertible seat until 40 pounds* *Booster seat* Lower Anchor and Tethers for Children (LATCH)- since 2002 Pedestrian/traffic injuries Don't leave unattended in car Keep trunks closed

Infant Safety

ASPIRATION- check for small objects, go around the house on hands and knees, feeding sitting up, small food bites SUFFOCATION- "Back to sleep", avoid extra blankets and pillow, avoid unsafe sleep, crib slats, 6cm apart, no crib bumpers, remove bibs, avoid bags, balloons, and buckets DROWNING- supervise baths, fence pools, keep bathroom doors closed, keep appliances shut FALLS- crib rails, car seats, supervise when on furniture, avoid scatter rugs, fence the stairs, keep furniture away from the window. BODILY DAMAGE- Secure furniture, supervise with animals, keep away sharp items CAR SEATS- Secure properly, ensure correct placement and seat for age/height/weight POISONINGS When mobile, check paint for furniture and toys- no lead All toxic substances on high shelf *Use appropriate containers for storage of cleaning supplies*, etc. *Keep plants out of reach* Child safe caps and all meds stored out of reach Caution with cosmetics and batteries Know poison control number *Give medications as a drug, not "candy"* Carbon monoxide detector in home *1-800-222-1222* BURNS *Smoke detectors checked q6months* Check temperature of all formula *Water heater set < 120 degrees* Check bath water Avoid cigarettes/ashes near child Flame retardant clothes Store all candles, matches, lighters in high place Caution with sun exposure, use sunscreen Guards around fireplace Electrical cords and outlets Pot handles to back of stove

Toddler Sleep

Average *11-12 hours* *1 nap/day through 2nd or 3rd year* *Move from crib to bed at height of 35 inches* Bottom bunk if bunk beds Bedtime resistance and fears (monsters) Need *bedtime rituals* - same hour, snack, stuffed animal or blanket If crying, graduated extinction

Infant Body Image, Social, and Speech Development

Body Image- *distinct bodies by 1 year* Social: Attachment *Separation anxiety- begins 4-8 months* *Stranger fear- 6-8 months* Speech: Coos Pronounces vowels by 2 months Verbalizes consonants by 5-6 months *Understand words such as "no, mama, dada" by 10 months* *Speaks 3-5 words with meaning - 12 months* (besides dada, mama)

Infant Fine Motor

DEVELOPMENT *know* Grasping object: 2 - 3 months <<<<Palmar grasp: 5 months>>>> Holds bottle: 6 months Transferring object between hands: 7 months Pincer grasp: 8 months - matures by 11 months Removing objects from container: 11 months Building tower of 2 blocks: 1 year *Acquisition of fine and gross motor skills occurs in a cephalocaudal and proximodistal sequence. cephalocaudal (head-to-toe) proximodistal (center to periphery) SKILLS 1 month Grasp reflex strong Hand predominantly closed 2 months Holds hands in open position Grasp reflex fading 3 months No grasp reflex, hands loosely open *Holds rattle*, will not reach for it Pulls at blankets and clothes 4 months Carries objects to mouth Grasps objects with both hands Plays with rattle, but cannot pick it up 5 months <<<<*Able to grasp voluntarily* - palmar grasp>>>> Plays with toes 6 months Holds bottle Secures a dropped object Grasps feet and pulls to mouth 7 months Transfer objects from hand to hand Rakes at small object 8 months Begins using pincer grasp Releases objects at will 9 months Has *crude pincer grasp* with thumb/index finger Preference for dominant hand 10 months *Grasps bell by handle* Crude release of object begins 11 months Neat pincer grasp Drops objects deliberately Puts object in container 12 months Attempts 2 block tower without success *Turns pages many at a time*

Infant Gross Motor

DEVELOPMENT *know* Head control- 2-3 months By 3 months of age, infants can hold their head well beyond the plane of the body. 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. Only slight head lag is evident when the infant is pulled from a lying to a sitting position, and by 4 to 6 months, head control is well established <<<<<<An infant who displays head lag at 6 months of age should have a developmental and neurologic evaluation.>>>>>> Rolling over: Age 5 months: abdomen to back Age 6 months: back to abdomen Sitting: age 7 months Crawls then creeps 8 months Crawling (propelling forward with belly on floor) progresses to creeping (on hands and knees with belly off floor) by 9 months Move from prone to sitting position: age 10 months Cruises -11months Sits from standing 12 months- some walking SKILLS 1 month Head lag 2 months Lifts head off mattress 3 months Head and shoulders off mattress 4 months Rolls from back to side 5 months Rolls from front to back 6 months Rolls from back to front 7 months Bears full weight on feet 8 months Sits unsupported 9 months Pulls to a stand 10 months Changes from prone to sitting 11 months Walks while holding on (cruises) 12 months Sits from a standing position http://www.cdc.gov/ncbddd/actearly/milestones/photolibrary/6months.html

Infant Psychosocial Development

Developing a sense of trust (Erikson): *Trust vs Mistrust* - birth to 18 months Infants trust that their comfort needs will be met *NEEDS*: Feeding Stimulation Comfort Mistrust: Occurs when gratification of needs is delayed *Social Modifications*: Grasping Biting

Infant Coping Concerns r/t 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 Infant shoes

School Age 6-12 years

GROWTH More graceful, slimmer appearance, improved posture, refined coordination Double their strength and physical capabilities Height increases 5 cm (2 inches)/year Weight increases 2-3 kg (4.4-6.6 pounds)/year *Prepubescence*- changes of *puberty begin around age of 9 years* *Begin screening for scoliosis* PSYCHOSOCIAL Erikson: *Industry vs Inferiority* Achieve a sense of accomplishment through acquisition of technologic and social skills *Extrinsic motivation*- grades and privileges, rewards, follow rules, list to win Need to find areas in which they excel Move away from egocentrism and can see other's views *Peer pressure begins to take effect* <<<<Friendships between same gender peers (*Best friends*)>>>> *Fears of ridicule* by peers and teachers COGNITIVE Piaget: *Concrete Operations* (7-11 years) Conceptual abilities are more flexible Masters concept of *conservation* Can see other points of view Able to *solve problems* Become *self-motivated* Tells time Understand emotions Understand bigger/smaller, left/right Classifies more *complex information* Understands rules of grammar and that a word can have many meanings AGE APPROPRIATE ACTIVITIES Competitive and cooperative play Clubs and peer groups *Board games* Hopscotch, jump rope Ride bicycles Building models Organized sports Crafts *Collect rocks, stamps, cards, coins, stuffed animals* SCHOOL Socialization Interactions with teachers Role models/mentors Stimulate intellectual development Parental involvement *Begin sex education* Ask what they know Be honest Stress- teasing, fears, work, social issues, *competition* Latchkey children- find activities, teach safety *scolliosis* DISCIPLINE Help the child interrupt or inhibit a forbidden action *Provide a more acceptable alternative behavior for future* *Provide reasons* to show why behavior is acceptable/unacceptable Corporal punishment not recommended *Withholding privileges, requiring recompense, imposing penalties, and contracting* are often success SLEEP 9-11 hours/night *No naps* Fewer bedtime problems Older kids might listen to music or read May get resistance NUTRITION Need a balanced diet. Diet often dependent on family's way of eating. Don't know what kids eat when away School lunch choices Junk food and fast foods common *Provide nutritious snacks* Role model Encourage physical activity *Limit screen time* Avoid frequent fast food MVAs Educate about seatbelts Maintain discipline Safe pedestrian behavior *Wear helmets* when riding bike, motorcycle, ATV, skateboards, scooters *Booster seat until adult seat belt fits properly (usually about 80 pounds) or 145 cm (4 ft, 9 in)* *Sit in back seat until age 13* Decreased incidence of unintentional injury since more coordinated and increased cognitive capacity Exposed to more environments and have less supervision Injury higher in boys, and death rate 2x girls BICYCLE SAFETY Wear properly fitting helmet Learn rules of road Ride with direction of traffic away from parked cars Teach hand signals Walk bike if busy area Keep hands on handlebars Use lights and reflectors, light clothes at night Wear shoes Don't ride double unless equipped BODILY HARM Play in safe places *Firearms locked* Respect for power tools and fireworks Protective equipment during sports Trampolines not recommended Window guards to prevent falls Teach address, phone, and stranger safety DROWNING *Teach to swim* Teach rules of water safety <<<<*Check depth before diving*>>>> Swim with a companion *Supervise when swimming* Use flotation devices in boats Fencing around pools Encourage breaks Learn CPR BURNS Caution with gasoline, bonfires, matches, fireworks, cigarettes, chemistry sets Teach safe cooking (microwave, avoid frying, steam burns) Avoid climbing and kites around wires Teach fire drills at home and school Smoke detectors Water heater at 120 degrees F Use sunscreen POISONINGS Educate about taking nonprescription drugs and chemicals, including aspirin and alcohol Say no to drugs Properly label dangerous products IMMUNIZATIONS 11-12 years Tdap booster Meningococcal vaccine-11,12 yo, booster 16-18 yo Need before college HPV vaccine-9-11yo, 2 month later, 6 months later Annual flu vaccine: injection or nasal spray 7th grade shots Prevents meningococcal infections Death, limb and digit amputation, scarring, hearing loss, and neurologic disability Ensure college freshmen in dorms and military recruits are vaccinated *Administer at age 11-12 Booster age 16-18 if first dose before age 16* Can get earlier with certain conditions with increased risk *HPV4 approved for males ages 9-26* *HPV2 or HPV4 for females* LATCHKEY CHILDREN: little parental supervision because parents always away working Teach safety *keep TV off, no naps*

Preschooler 3-5 years

GROWTH Preschoolers should gain 2-3 kg (4.5-6.5 pounds)/year Grow about 6.5-9 cm (2.6-3.5 inches)/year More graceful and improved posture FINE MOTOR 3 years Copies circle and cross Tower of 9-10 cubes 4 years Uses scissors Laces shoes but can't tie bow 5 years *Ties shoes* but may need help Uses scissors and pencil well GROSS MOTOR 3 years Rides tricycle Jumps off bottom step and broad jumps Stands on one foot for a few seconds 4 years Skips and hops on one foot Throws a ball overhead 5 years Jumps rope, skates, swims Walks backward heel to toe Throws and catches ball easily PSYCHOSOCIAL DEVELOPMENT Erikson: <<<*Initiative vs Guilt*>>> match punishment/restrictions with actions New experiences, but may not be able to accomplish *Energetic learning through play and work* <<<Master skills requiring independence such as *dressing and feeding self*>>> <<<<*Fear of bodily harm*: dark, animals, procedures>>>> *Sex role identification* *Less separation & stranger anxiety* Preschool and kindergarten start at this time. Activities of quiet play, outdoor activity, group activity, creative or free play, and snack/rest periods Provides language, physical and social development Temperament and adaptation Present school as exciting and pleasurable Barriers: less individual attention than home, prolonged separation, and expected learning More exposure to illness *Male night time incontinence* COGNITIVE DEVELOPMENT Piaget: *Preoperational phase* (age 2-7 years) Pre-conceptual thought <<<<*Animism*>>>> *Magical thinking* - <<<being ill is punishment>>>>, imaginary friends Centration *Egocentrism* <<<<not good with time, "close to dinner time/bed time">>>> Intuitive thought (later preoperational phase) Classify information, *aware of cause/effect around 6-7* Understand more past, present, future <<<<*Explain time with events*: "Mom will come after lunch">>>> LANGUAGE: Speaks in sentences 3-4 words at 3-4 years, 4-5 words at 4-5 years Vocabulary increases to over 2100 words by age 5 increased comprehension - be aware PLAY *Associative play*: group play without rigid rules Tricycles, wagons, sports equipment - safety Construction sets, alphabet or number flash cards Electronic games and educational TV for learning - limit Paints, crayons, musical toys Books *Imaginary friends are normal* Imaginative or dramatic play such as dress up clothes, dolls, housekeeping toys, telephones, puppets, cars/trucks *THEY CHEAT* TO WIN - let them win http://www.youtube.com/watch?v=dbMHyRyuPqI- *role play* SLEEP Need about 12 hours sleep/day Some may nap Evaluated bedtime and keep routine *Do not let kids sleep with parents* Use *night light* for fears of dark May have *nightmares or sleep terrors* NUTRITION *Consume about half the calories as adults (900 cal)* <<<<*Picky eating*, may improve by age 5 - *offer frequent, healthy snacks*>>>> Replace high fat foods with low fat choices when possible Ensure intake of *Ca and Vit D*, healthy choices, no more than 30% fat Obesity: *encourage healthy food choices*, *increase activity to 1-2 hours/day*, *limit screen time to under 2 hours* INJURY PREVENTION Motor skills, coordination, and balance are improved Less prone to falls Less reckless Aware of potential dangers Essential for parents to practice what they preach <<<<Focus on teaching preschoolers safety principles!>>>> *bikes* MVA/INJURIES Pedestrian vs motor vehicle injury increases. <<<<*Teach Pedestrian Safety. Look left, right, and left again*.>>>> *Helmets!!* Need supervision when playing outside Sit in approved *forward facing car seats in the back seat* away from airbags *Car seats until 4 years/40 pounds* Move to booster seats in the back seat until 4 ft 9 in tall may cause death in children after 1 stay in back till 13 years old SAFETY Bodily injury Firearms, stranger safety, helmets and pads Burns Hot water heaters, smoke detectors, sunscreen Drowning Supervision in bathtubs, supervise near water, *teach to swim* Poisoning Lead paint, plants, cleaners/chemicals, phone for poison control center, medications out of reach, carbon monoxide detector IMMUNIZATIONS 4-6 years DTaP IPV MMR Varicella Annual flu vaccine: injection or nasal spray kindergarten shots

Toddlers 1-3 years

GROWTH by 30 months - birth weight x4 3 inches/year

Infant Head Circumference + Fontanels

HEAD CIRCUMFERENCE: determinant of brain growth Average at birth- 33-35 cm (13-14 inches) 6 MONTHS: increases 1.5 cm/month 1 YEAR: increases 0.5 cm/month from 7-12 months By 1 year, the HC should increase by 33% Average head circumference: -43 cm at 6 months -46cm at 12 months <<<<<FONTANELS:>>>>>> Anterior fontanel closes by age 12-18 months. - 14 months on average Posterior fontanel closes by age 6-8 weeks. - NOT palpable after closing!!

Time ranges

INFANTS 1 month - 1 year NEWBORN birth - 1 month

Healthy People 2020 Objectives in Infant Care

MICH-20 Increase the proportion of infants who are put to sleep on their backs MICH-21 Increase the proportion of infants who are breastfed: MICH-21.1 Increase the proportion of infants who are ever breastfed MICH-21.2 Increase the proportion of infants who are breastfed at 6 months MICH-21.3 Increase the proportion of infants who are breastfed at 1 year MICH-21.4 Increase the proportion of infants who are breastfed exclusively through 3 months MICH-21.5 Increase the proportion of infants who are breastfed exclusively through 6 months MICH-22 Increase the proportion of employers that have worksite lactation support programs MICH-23 Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life MICH-24 Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies

Infant Age Appropriate Toys

Nesting toys Teething ring Mobile Rattles 0-6 months - high contrast

Toddler Cognitive Development

Piaget- *sensorimotor stage (until 2 years)→ preoperational stage* Cannot distinguish safe from unsafe Object permanence: Have *memories* of events Domestic mimicry (playing house, role play) Language: 2-3 word phrases, 300 words by 2 years Increased concept of language Beginning sense of time ("Wait a minute")

Maturation of Systems

Slowing of RR Slowing of HR Head growth -33-35 cm at birth *Head circumference increases by 33% first year*. Differentiation of the nervous system IMMUNE: maternal IgG - newborn - 3 months own synthesis of IgG by 1 yr IgM produced at birth own synthesis of IgM by 9 months THERMOREGULATION - shivering - thermogenesis Increased adipose tissue during the first 6 months insulates the body against heat loss. RENAL: At birth, *75% 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 40% at term to 20% in adulthood. The high proportion of ECF, which is composed of blood plasma, interstitial fluid, and lymph, predisposes the infant to a more rapid loss of total body fluid and, consequently, dehydration. *The loss of 5% to 10% of the term newborn's initial birth weight in the first 5 days of life is attributed to ECF compartment contraction*, enhanced renal tubular function, and rapidly increasing glomerular filtration rate Urine is voided frequently and has a *low specific gravity (i.e., 1.000 to 1.010)*. At term, most infants produce and excrete approximately *15 to 60 mL/kg/24 hr*, and an output of OLIGURIA: < 0.5 mL/kg/hr after 48 hours of age Communication AUDITORY AND PERCEPTION: *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 age 4 months. *Depth perception (stereopsis)* begins to develop by age 7 to 9 months 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. HEMATOPOIETIC: *physiologic anemia 3-6 months* Significant changes in first year 1st 5 MONTHS: fetal Hgb present in large quantities Adult Hgb steadily increasing, Fetal Hgb has a shorter lifespan - results in physiologic anemia ~3-6 months High levels of HgbF depress the production of erythropoietin, a hormone released by the kidney that stimulates red blood cell production. Hemoglobin levels decrease to a certain point at which tissue oxygenation needs stimulate erythropoietin, and erythropoiesis resumes, forming new red blood cells The occurrence of physiologic anemia is not affected by an adequate supply of iron. However, when erythropoiesis is stimulated, iron supplies are necessary for the formation of hemoglobin. DIGESTION Maturation of digestive processes Drooling - 3 months - poorly coordinated swallowing reflex - more digestive processes functioning *Digestive enzymes specific to breaking down milk first 5-6 months* Then Amylase, Lipase levels increase to break down complex carbohydrates and increase fat absorption respectively.

Infant Sleep

Variable Approximately 15 hours/day of sleep 4 MONTHS:, most infants sleep 9-11 hours at night Breastfed infants sleep shorter times than bottle fed *Establish bedtime rituals* Parent present? Graduated extinction? *INFANT SAFE SLEEP* ABC's: Alone Back Crib Safe to Sleep Campaign https://www.nichd.nih.gov/sts/news/downloadable/Pages/default.aspx#photos https://www.nichd.nih.gov/publications/pubs/Documents/SIDS_QA_HealthCareProviders.pdf Co-sleeping http://cosleeping.nd.edu/safe-co-sleeping-guidelines/ Back to Sleep Campaign Baby's Anatomy When on the Stomach and on the Back: *Back sleeping does not increase the risk of choking*. In fact, babies may be better able to clear fluids when they are on their backs, possibly because of anatomy. When a baby is in the back sleeping position, the trachea lies on top of the esophagus. Anything regurgitated or refluxed from the esophagus must work against gravity to be aspirated into the trachea. When a baby is in the stomach sleeping position, anything regurgitated or refluxed will pool at the opening of the trachea, making it easier for the baby to aspirate or choke. https://www.nichd.nih.gov/sts/news/downloadable/Pages/baby_anatomy_image.aspx *Always place babies on their backs to sleep at night and at nap time*. Babies who sleep on their backs are less likely to die of Sudden Infant Death Syndrome (SIDS). *Babies should always sleep in a crib*. The safest place for a baby is in the same room as the parents but alone in a separate sleep area. *Keep loose objects, soft toys, and bedding out of the baby's sleep area*. Do not use pillows and blankets in a baby's sleeping area. A baby should sleep in a crib with only a tight fitting sheet. *Avoid letting your baby overheat during the night*. A baby should be *dressed lightly for sleep*. Set the room temperature in a range that is comfortable for a lightly clothed adult. *Do not use crib bumpers*. These do not reduce injuries and can cause suffocation. *Avoid smoking*. Both maternal smoking during pregnancy and secondhand smoke after birth should be avoided. *Breastfeeding is recommended for at least the first six months of life*. Breastfeeding is associated with a reduced risk of SIDS. http://www.tn.gov/health/article/safe-sleep-tips firm mattress

links

https://quizlet.com/114728707/maternal-child-the-growing-child-flash-cards/ https://quizlet.com/127250585/peds-exam-2-evovle-chapter-31-the-infant-and-family-flash-cards/