Growth &Development
Part 1: Infants/Toddlers
Chapter 16
The Infant
Head Lag
– A. 1 month
– B. 2 months
– C. 4 months
CLINICAL ALERT
Head lag at 6 months of age needs a developmental/neurologic evaluation
Review Resources MPN Chap 15
Overview of G&D
Figure 15.1: Development of Muscular….p 349
Figure 15.2: Assessing Length and Height, p 349
Figure 15.3: Changes in Body Proportions, p 350
Figure 15.4: Growth chart, boys: p 351, girls 352
Table 15.1: Variations of Family Living p 354
Table 15.2: Cultural Influences on the family 356-60
Table 15.3: Comparison of Developmental theories:
Erikson, Freud,, Kohlberg, Sullivan, Piaget, p 361
Review Resources
MPN Chap 15
Figure 15.5: Maslow Hierarchy of Needs
Table 15.4: Piaget’s Theory p 362
Table 15.5: Growth & Development Parent p 363 Table 15.6: Culturally Diverse Food
p 364
Table 15.9: Nsg Intervention Nutritional p 371-2
Figure 15-10: Permanent Teeth p 375
Developmental Dental Hygiene p 376
Table 15-10: Medical and Dental Health p 378
Table 15-11: Development of play p 378
Review Resources
MPN Chap 16: Infant
Figure 16.1: Average VS for infant, p 381
Figure 16.3: Locomotion, prehension, perception
p 382-38
Table 16.1: Physical Development, Social Behavior,
P 384-389
NCP 16.1: Family Care Plan, p391
Screening Tools: DDST etc p 392
Table 16.3: G&D of Mealtime p 394
Figure 16.4: Feeding Skills p 395
Table 16.4: Toys for the first year
Summary of Major Developmental Changes of 1st year p 397
Review Resources
Chap 17: Toddler
Table 17.1: Physical/Social Abilities Toddler p 400
Table 17.2: Language Milestones p 402
Table 17.3: Child with Communication Disorder p 402
Box 17.1: Screening for Autism p 403
Table 17.4: Behavior Problems p 404
Table 17.5: Approximate Servings p 406
Prevent Hazards with Toddlers p 409-410
Figure 17.5: Infant Car Seats
Review Resources: Fund: Chap 11
Developmental Theories
Table 11.1: Comparison of Theories p 138
Freud Stages: Oral, Anal, Phallic/Oedipal, Latency, Genital p 138-139
Erikson Stages: Trust, Autonomy, Initiative, Industry, Identity, Intimacy, Generativity,
Integrity, p 139-140
Chess/Thomas: Easy, difficult, slow to warm p 141
Piaget Periods: Sensorimotor, Pre-operational, Concrete, Formal Operations p 142-
143
Bandura: Social Cognitive Theory p 143
Kohlberg’s 6 Stages Moral Development: p 144
Review Resources
Fund: Chap 12: Conception Through Adolescence
Box 12.1: Developmental Age Periods, p 149
Table 12.1: Developmental Behaviors of School/Age and Adolescents p 162-163
Table 12.2: Injury Prevention School Age p 166
Table 12.3: Health Promotion School Age p 167
i-clicker question
application/teaching, learning
The student nurse is presenting a case conference on Freud’s psychosexual stages
of development, specifically that of the 12-18 month old child. Which of the following
relates specifically to this stage?
A) oral stage: sucking and oral gratification
B) anal stage: toilet training
C) phallic/Oedipal: focus on genital organs
D) latency: sexuality repressed
Freud 5 Stages Fund p 138-139
See Table 11.1 p 138
Freud Stages:
Oral: birth-12-18 months: sucking vital, pleasurable
Anal: 12-18 months: pleasure moves to anal, toilet training issues
Phallic/Oedipal: 3-6 years: genital areas, penis envy, exploration, imagination
Latency: 6-12 years sexual urges repressed
Genital: puberty-adult, final stage, earlier sexual urges awaken
Freud believed: Components of personality develop thru stages
Erikson, Fund p 139-140
7 Stages of Development
Trust vs Mistrust: Birth-1 year
Autonomy VS Shame and Doubt: 1-3 yrs
Initiative VS Guilt: 3-6 years
Industry VS Inferiority: 6-11 years
Identity VS Role Confusion: Puberty
Intimacy VS Isolation: Young Adult
Generativity VS Self Absorption/Stagnation: Middle Age
Integrity Vs Despair: Old Age
Erickson’s Theory of Development
Personality development theory
Infant stage: Central task is dealing with
– Trust versus Mistrust
Toddler Stage: Central task is dealing with
– Autonomy versus Shame & Doubt
i-clicker question
application/teaching, learning
The nurse is providing instructions to a new mother regarding the psycho-social
development of the infant. Using Erikson’s theory, the nurse would instruct the
mother to:
A) Allow the infant to signal a need
B) Anticipate all the needs of the infant
C) Attend to the crying infant immediately
D) Avoid infant during the first 10 minutes of crying
Jean Piaget Theory of Cognitive Development: Fund 142-143
Period 1: Sensorimotor: Birth-2years
– Infant deals with environment
Period 2: Pre-operational: 2-7 years
– Learns to think with symbols and mental images
Period 3: Concrete: 7-11 years
– Mental operations, thinks before acts
Period 4: Formal Operations: 11-adult
– Abstract and theoretical: world peace, justice
Kohlberg’s 6 Stages Moral Development: Fund: p 144
Expanded from Piaget’s cognitive theory
A leader in moral development theory: criticized age/gender/cultural bias
Level 1: Preconventional Reasoning: why?
– Stage 1: Punishment/Obedience
– Stage 2: Instrumental Relativist Orientation
Kohlberg’s 6 Stages Moral Development: Fund: p 144
Level 2: Conventional Reasoning:
– Stage 3: Good Boy/Nice Girl
– Stage 4: Society Maintaining
Level 3: Post-conventional Reasoning
– Stage 5: Social Contract
– Stage 6: Universal Ethical Principle
i-clicker Question
comprehension/teaching learning
The nurse is teaching a growth and development class in the clinic setting. When
describing the developmental theories the nurse knows that infancy is described by
Erikson to be a time to master which developmental milestone?
A) Oral phase
B) Trust vs Mistrust
C) Pre-conventional
D) Sensorimotor
Assessing Infant Growth and Development
The nurse must understand the normal range for milestone achievement to do the
following:
– Assess the progress of infants’ growth and development
– Initiate early referral and follow-up
The most common cause for concern is an atypicality for age slowing any aspect of
development
Community-Based Care
The primary responsibility of the nurse is to guide the parents and assist in the
development of skills necessary to ensure proper growth and development of their
child
Infant Nutrition
Bottle-fed infants feed at 3-4 hour intervals
Breastfed infants feed at 2-3 hour intervals
Breast milk or iron-based formula for first year
Solid foods introduced at 5-6 months
– Begin with 1 teaspoon
– Offer new foods at 4-7 day intervals
– Offer single-ingredient foods
Growth & Development
Definitions:
– Growth = increase in structure
– Development = increase in function
– Maturation is a process whereby inherited tendencies begin to unfold independent
of any special practice or training.
i-clicker question
application/teaching, learning
The nurse is teaching a child and parenting class. A mother of a toddler asks when it
is safe to place the car seat in a face forward position. The BEST response of the
nurse would be
A) When the toddler weighs 20 lbs and is 1 year old
B) When the toddler weighs more than 40 lbs
C) It should NOT be placed in face forward w/o safety locks in the car
D) The seat should never be placed in face forward position due to safety reasons
5 Basic Principles of
Growth/Development
1. Orderly sequence
2. Continuous characterized by growth spurts
3. Highly individualized
4. Varies at different ages, specific structures
5. Represents a total process involving the whole child
4 Periods of General
Physical Growth Norms
– 1. very rapid during babyhood
– 2. slow, steady during childhood
– 3. growth spurts during puberty
– 4. period of decreasing growth & attainment of maximum height
General
Physical Growth Norms
Height
– Infant: average 20”
– 1st year: 10” growth
– 2nd year: 5” growth
– Preschool: 3” growth
– 6-10 years: 2”growth
– Peak at: 14 yrs for boys & 12 years for girls
General
Physical Growth Norms
Weight
–
Birth: average 7-1/2 #
–
5-6 months: doubled
–
1 Year: tripled weight
–
Drop in weight after first year
–
Pre-school: 5 lbs/year
–
School: Slight increase in weight
Principles of
Motor Development
1. Cephalo-caudal: Head to feet
2. Proximal-Distal: Central to extremities
3. Diffuse to Specific:
The sequence is similar for all children but the rate at which they develop varies.
Principles of
Motor Development
Prehension: obtained by 1 year-15 month
– reaching, grasping, raking movements apposition of the thumb and fingers,
requires hand-to-eye coordination.
– Locomotion Sequence: page 484-485
Guidelines for Critical Thinking in Case Scenarios
see syllabus p 20-23
What more information is needed?
Why is client here today? Chief complaint…
Medical Diagnosis?
Pertinent lab, diagnostic, drug, client history info?
Priority nursing assessments? Use Nursing Process.
Priority 3-4 Nursing Diagnoses?
Priority 3-4 nursing priorities, interventions?
Priority: psycho/social/cultural/teaching needs?
What needs to be communicated to HC team?
What needs to be charted on EMR/client record?
Key Points
Boys are taller & heavier than girls except in the years preceding puberty
Girls reach adult proportions sooner than boys
Birth: Head very large = 1/4 body length
Key Points
Adult: Head 1/8 to 1/10 total body length
Midpoint for infant is the umbilicus
Midpoint for adult is the symphysis pubis
General Body System
Changes in G/D
Bone Formation
– Fetal development connective tissue becomes cartilage
– Cartilage persists between the shaft & end of the bone
– By 5 months gradually replaced by bone
17 years for girls
19 years for boys
General Body System
Changes in G/D
Tooth Formation
– Structures formed in fetal life.
– Birth: have all deciduous teeth & 6 year molars are developing
2 lower @ 5-7 mos.
6 teeth by 1 year
20 teeth by 21/2 yrs
No tetracycline
General Body System
Changes in G/D GI System
G-I System
– Immature to digest
– Digest protein effective
– Amylase deficient till 3 months
– Lipase decreased during 1st year
– Liver immature
– Drink from cup by 8-10 months
General Body System
Changes in G/D GI System
G-I System
– Sucking reflex present
– Swallowing not effective till 6 months
– Protrusion till 4 mos.
– Physiologic anemia at 2 months with conversion to adult hemoglobin by 5-6
months
General Body System
Changes in G/D Immune System
Immune System
– Functional by 2 mos.
– Produces IgG & IgM by 1 year
– IgA, IgE and IgD not plentiful till preschool
– Protect from infection
General Body System
Changes in G/D: Cardio-respiratory
Cardiovascular/Respiratory systems:
– 120-160 per minute at birth
– 100-120 per minute by 1 year
– Pulse may slow with inhalation (sinus arrhythmia)
Respiratory:
– Lumen of respiratory. tract is small/mucous production is inefficient, protect from
infection
General Body System
Changes in G/D Other Systems
Other Systems
– Ability to adjust to cold temps by 6 mos.
– Kidneys immature
– Endocrine immature in response to pituitary.
– Infant unable to react to stress effiiciently
– Fluids: extracellular is 35% compared to 20% in adults
Teaching guidelines for common infant concerns
Colic
– Up to 3 mo, hold infant in arms prone
Sleep
– On back, own pattern
Pacifier
– Select for safety/teeth
Diet
– Breast milk/formula, Q 2-3 hrs up to 4 hrs
Teaching guidelines for common infant concerns
Crying
– Different types: Pain, hunger, tired etc
Elimination: Voids 6-8xday, BM 1-2 x per day
Safety:
– Car, toy, fall prevention, back to sleep, poison,
– small items in mouth, childproofing home
Immunizations
– 2 and 4 months: DPT, OPV, H Flu (Hib)
– 6 mo: DPT, Hib, HepB
Developmental screening tests (DDST)
All States are required to assess for developmental disabilities before age5
(All Handicap Children Act, 1986)
Denver Developmental Screening test (DDST)
– Tests social, fine-motor
– Language, gross motor
– Birth-6years
Developmental screening tests (cont’d)
Clinical Linguistic & Auditory Milestone Scale
– (CLAMS), Language milestones birth-3years
Ages & Stages (ASQ) Questionnaire 4-48 months
– Infants emerging personality, reflexes, alertness, orientation to voice, visual stimuli
Brazelton Neonatal Behavioral Assessment
Other Developmental screening tests
Denver Home Screening
– Child rearing in home
Early Language Milestone (ELM)
– Expressive, receptive, visual language birth-3yrs
Infant DDST (Denver Developmental Screening Test Key Points
Birth to 3 months
– Personal-Social
Smiles responsively
Then spontaneously
– Fine Motor
Follows past midline
grasps rattle & holds hands together
Infant DDST (Denver Developmental Screening Test Key Points
– Birth - 3months
– Language
Laughs, squeals, vocalizes without crying
– Gross motor
rolls over; lifts head 90
Infant DDST (Denver Developmental Screening Test Key Points
4-6 months age
– Personal-Social
works for toy, feeds self
– Fine Motor
palmar grasp, reaches for objects
– Language
turns toward voice, imitates speech
– Gross Motor
some wt. bearing, sits with support
Infant DDST (Denver Developmental Screening Test Key Points
7-9 months age
– Personal-Social
Indicates wants
Pat-a-cake, bye-bye
– Fine Motor
crude pincer grasp
takes 2 cubes & bangs
passes hand to hand
Infant DDST (Denver Developmental Screening Test Key Points
– 7-9 months
– Language
nonspecific jabbers
– Gross motor
creeps, pulls to stand
Infant DDST (Denver Developmental Screening Test Key Points
10-12 months age
– Personal-Social
plays ball, imitates activities, drinks from cup
– Fine Motor
Neat pincer grasp
– Language
specific jabbers
– Gross motor
stands alone, begins walking
i-clicker question
comprehension/teaching learning
The nurse is teaching a healthy eating class. To prevent and detect allergies the
nurse would recommend to the mother of an 8 month old which of the following:
A) introduce 1 ingredient food at a time per week
B) mix food with one the infant likes
C) mix food with formula
D) offer 2 new foods per week at a time
Feeding: when/how to prepare
puree, baby grinders, safety, no honey, ice cube trays
Birth-3mo:
cries, tense body: breast/formula
3-6 mo:
grasps bottle, fusses, tongue protrudes
– Breast or formula
Feeding: when/how to prepare
puree, baby grinders, safety, no honey, ice cube trays
6-9mo:
reaches for spoon and food, shakes “no”
– 6mo:Possible first solids, rice cereal, check with MD
– 7 mo: add fruit, finger foods(toast)
– 8 mo: add veggies, add food slowly, 1 at a time
Feeding: when/how to prepare
puree, baby grinders, safety, no honey, ice cube trays
9mo:
uses spoon independently, refined pincer
– Holds bottle, add: chopped/minced foods (meat, beans, cheerios)
10-12 mo:
attempts to feed self, vocalizes, cup, juice, solids- 12 mo gradually add: fish, OJ, well
cooked table
i-clicker question
A mother of a 1 year old is concerned her infant is overweight. He was 8 lbs at birth
and is now 24 lbs. She states her family has a history of weight problems and wants
to start the infant on low-fat milk. The BEST response of the nurse would be:
A) “That would be a good idea, childhood obesity is on the rise”
B) “Start the infant on whole milk, the baby’s weight is normal for 1 year”
C) “The infant is underweight, the MD may want her to use a formula supplement
D) “The infant is still growing, weight loss will occur when he’s more active
Toddlers!
Chapter 17
Toddler: Psychosocial Development
Autonomy vs. shame and doubt: Erikson
Negativism
Ritualism
Toddler: Physical Development
Gains 4-6 pounds per year
Grows 4 inches per year
Bowel and bladder control achieved by 2 1/2-3 years
Primary dentition (deciduous teeth) complete by 2 1/2 years
Guidance and Discipline
Goal is to teach toddler self-control with positive self-esteem
Use a positive approach
Time-out: 1 minute per year of age
Toilet Independence
Myelinization of spinal cord complete by 2 years: voluntary control of sphincters
Toilet Training:
day 3yrs, nite, 4 years, accidents thru 4 years, attention, fluids at nite, regression
Look for signs of readiness
Toilet Training
Physical Readiness
– ability to remove clothing
– willingness to let go of a toy when asked
– ability to sit, squat, & walk well
– has been walking for 1 year
– Stays dry approximately 2 hours
– Able to communicate that he or she is wet or needs to urinate/defecate
– Willing to sit for at least 5-10 minutes
Toilet Training
Psychologic readiness
–ability to notice wet diaper
–may indicate he wants to be changed
–ability to communicate a need to go to the bathroom
–desire to please his parent by staying dry
Toilet Independence (pg 405)
Temperament/development 18-24 mo, regressions
Readiness: vol anal, urethral control, wakes up dry
Communicate, curious of BR
Able to sit on potty 5-10min
Imitate parents/siblings
Training pants, potty chair, feet touch floor
Usually bowel first, then bladder(2 hrs dry)
Rewards, no demands/threats
Toddler: Nutrition
Fluctuating appetite with strong food preferences
Limit milk to 24 ounces per day
Serving size: 1 tbsp of food per year of age
Likes finger foods: consider safety
Ritualism at mealtime
i-clicker question
comprehension
At what stage of development would you expect the child to walk alone and crawl
upstairs?
A) 8 months
B) 12 months
C) 15 months
D) 18 months
Developmental Milestones for Toddler ( see chart pg 400)
12-16mo:
imitates adults, cup, spoon, walks, words, object permanence
16-18 mo:
parallel play, rituals, walks, symbolic language(bye-bye) realizes cause/effect
Developmental Milestones for Toddler ( pg 400)
24 mo:
independent “mine” egocentric “NO”, runs
Throws, climbs, jumps, plural words, explores
36 mo:
toilet independence, sex roles, shares, balances, jump 1 foot, conversation “why” 2
colors
Screening for Autism (box pg 403)
See: Child with Communication Disorder (pg 402)
No pointing, gesturing (bye) by 12 months
No single words by 16 months
No spontaneous 2-word phrase by 24 mo
Loss of achieved language or social skills
R/O lead poisoning, hearing loss
Normal Behavior Problems In Early Childhood (see box pg 404)
Sleep:
– nightmares (36mo), ritual (2-3)
Head banging/rocking 1-4years (release tension)
Temper Tantrums:
peak at 2yr-4, frustrated, simple time outs 1 min/year, consistency, rewards
Normal Behavior Problems In Early Childhood
Inability to separate: separation anxiety
– up to 3 yrs, shy, self concept, manipulation, fear abandonment, be concrete, avoid
parent anxiety,spend time in new environment,
Normal Behavior Problems In Early Childhood
Aggressive/sib rivalry, negativism :
– coop play 3-5, attention, hitting/displeasure, doll play
Discipline:
– teach rather than punish, limits: distraction, reward/praise, time outs in safe place
Other toddler concerns
Day Care
Nutrition, amounts, types
Injury prevention: leading cause of death
Cars, Burns, Falls, suffocation, choking
Poisons, Drowning, Elec Shock, Bites
Stranger safety
Toys and play(water, buttons)
Childproofing the home (paint, drawers, outlets…)
Behavior Indicators
Infant versus Toddler: Infant
Crying is only way of communicating needs
Quieting usually means needs are met
Fear of strangers around 7-8 months
Some differences in personality of quiet versus active
Behavior Indicators
Infant versus Toddler: Toddler
Does not separate easily from parents
Negativistic
Prefers rituals/routine
Active physically
Self asserted and frustrated with limits
Temper tantrums
“mine”-
favorite “security object”
Physical Growth Infant versus Toddler: Infant
Teething:
– generally begins by 6 months
– “Baby” teeth are deciduous
– 1st two teeth: usually central lower incisors
– By 1 year: 6-8 teeth
– Introduce tooth brushing as a ritual
– By 30 months all primary teeth
– 1st dental visit by age 2 years (12-18 months)
Fontanels:
– posterior is closed by 6-8 weeks
– anterior remains open
– anterior closes between 12-18 months
Other Toddler Points
Posture/Gait:
– significant lordosis & protrusion of abdomen
– walks like a duck with wide based gait and side to side.
Vision:
– Full binocular vision well developed
– 20/40 visual acuity of toddler
Toddler DDST Points
12-18 months age
– Personal-Social
imitates housework, uses spoon, removes own clothes, drinks from cup, feeds
doll
– Fine Motor
scribbles, builds tower with 2-4 blocks
Toddler DDST Points
– 12-18 months:
– Language
6 words or more, points to body part
– Gross motor
kicks ball, walks
Toddler DDST Points
19-24 months age
– Personal-Social
puts on clothing, washes/dries hands, brushes teeth
– Fine Motor
builds with 4-6 cubes
imitates vertical line
Toddler DDST Points
– 19-24 months:
– Language
combines words, names picture
– Gross motor
throws overhand, jumps in place
Toddler DDST Points
Personal-Social
– Puts on Tshirt, Can name a friend
Fine Motor
– Wiggles thumbs, Builds tower of 8 cubes
Language
– Knows 2 action verbs, and 2 adjectives, Names color
Gross Motor
– Balances on 1 foot briefly, pedals tricycle
i-clicker question
Which of the following toys would be most appropriate for the nurse to provide to the
2 year old?
A) puzzle
B) wagon
C) golf set
D) farm set
E) blocks
Play and Toys
Solitary for infant vs. Parallel for toddler
Colors for infant: black, white, red
See toys section of Addendum
Safety is key issue in appropriate toy selection
Play and Toys
Stimulation with age appropriate toys
Trial & error period for toddlers(very curious)
Object permanence by 19-24 months
Just beginning to retain mental experiences & internalize by age 2. 300 words by age
2.
i-clicker question
The nurse is teaching a parent child safety class. Prevention is the key. The nurse
explains the leading cause of death for infants under 1 year can be prevented by:
A) using an approved infant car seat
B) keeping hot items out of reach
C) locking all household poisons
D) baby-proofing the house cupboards/cabinets
Toddler Stage Developmental
Table 15.3: Comparison of Developmental theories:
Erikson, Freud,, Kohlberg, Sullivan, Piaget, p 361 Freuds (anal stage)
focused on mastery of bowel and bladder functions.
2-2 1/2 begin gender identity. focused on genitals
Toddler Stage Developmental
Separation anxiety is especially significant for toddlers
Need favorite toy or blanket etc.
bedtime protests common
Me, Mine, and No
Infant Stage Developmental Summary
Fears: fear of strangers at 7-8 months.
Separation anxiety common at 7-9 mo.
Aware of scolding at 9 months
Infant Stage Developmental Summary
Socialization:
– 1 month = faces
– 2 months=social smile
– 3 months=laugh
– 4 months=cries if left
– 5 months=cries if objects removed
– 7 months=fear of strangers
– 12 months=Dances