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Copy of N404: Infant Growth and Development

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Sondae Stevens

on 5 March 2017

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Transcript of Copy of N404: Infant Growth and Development

Nutrition / Infant and Toddler Growth and Development
A young couple comes to your clinic for their prenatal visit and you are discussing infant feeding. The mother states that she is concerned that human breast milk may not provide all the nutrients that the baby needs. According to the American Academy of Pediatrics, if her baby is exclusively breast fed, when should the child begin receiving oral vitamin D supplementation?
Within the first month of life
2 months
4 months
6 months
Within the first month of life
AAP recommends breastfed & formula fed <33 oz/day receive Vit D supplement. This can be waived with an adequate VitD level in the baby.
Preterm: < 37 weeks' gestation
Neonate: <1 month
Infant: 1 month to 1 year
Toddler: 1 to 3 years
Preschooler: 3 to 6 years
School-Age: 6 to 12 years
Adolescent: 12 to 18
Higher calorie/kg intake
Preterm Infant
Ounce for ounce, this age has the highest metabolic rate and intake requirements of all ages.
School Age
Need 2000-3000 calories per day (depending on activity level) due to rapid growth
Problems with feeding:
poor suck
uncoordinated suck
too small stomach
poor intestinal absorption
renal immaturity
complicated by any other medical problems
Breast is Best!! (but may need fortification)
Nurses have very important role in teaching parent how to feed their baby.
Women who eat a traditional American diet should supplement breastfed infants with Vit D. If mom is deficient (blood test) supplement from the first days of life until they drink over 32oz of cow milk or formula with 400IU/day.
Top US recommendation: breastfeed exclusively for 6 months and continue breastfeeding for full 12 months.
The WHO recommends two years
Cereal at 6 months optional (Fe content important)
Veggies first at 6-8 months, then fruits.
No honey before 1 year!
Brush those teeth!!!
Caries are the most common preventable disease in Pediatrics.
Wean between 6 and 12 months
A time of physiologic anorexia
Finger foods on the GO!
Small portions! (about 1 Tbsp/year)
Limit juice!!!
4-6 oz/day

24 to 28 oz of low-fat milk.or mi substitute
3 meals + 2 snacks
Social meals.
Meals become more social
Food jags
Limit juice!!
Limit fast food
Include in meal preparation
metabolic needs change through growth spurts
Nutritional modeling is key!
family meals important
Cow milk is unnecessary if calcium and Vit D are obtained elsewhere. 24-28 oz max per day.

Monitor closely for overweight and obesity. This is less likely if candy and fast food are introduced late...kids can't form bad habits until they are taught bad habits.
Barriers to healthy eating
availability of "junk food"
lack of parental involvement
media messages
calcium very important, especially for girls dark leafy greens are best
often using supplements for sports
Measurements include weight (double by 5 mos. triple by 12 mos), length ( birth length increases by 50% by the age of 12 months.), and head circumference ( head circumference averages
between 33 and 35 cm (13 and 14 in). Standing height begins once child can stand.
BMI calculations begin at 2 year
Appropriateness of value is age dependent

>85%: overweight

>95%: obese

>99%: severely obese
Put the following gross motor milestones in the correct sequence:
A. sits without support
B. head control
C. rolls over
D. when prone, supports weight on forearms
E. pulls to stand

Put the following gross motor milestones in the correct sequence:
1. head control
2. when prone, supports weight on forearms
3. rolls over
4. sits without support
5. pulls to stand
Neurologic System
head circumference is indicative of brain growth
anterior fontanel usually open to 12-18 months for brain growth
reflexive behavior replaced by purposeful movement
Primative Reflexes

Protective Reflexes
asymmetric tonic neck
plantar and palmar grasp
Babinski (only one that lasts close to 1 year)
Periodic breathing
Increased risk for respiratory infection:
narrow nasal passages
more compliant trachea and chest wall
shorter and narrower bronchi and bronchioles
funnel shaped larynx
larger tongue
few alveoli
lack of IgA in upper respiratory tract
Respiratory System
heart doubles in size over 1st year
Newborn: 80 to 180/min (depending on activity)
1 week to 3 months: 80 to 220/min (depending on activity)
3 months to 2 years: 70 to 150/min (depending on activity
BP increases from around 60/40 to 100/50
peripheral capillaries mature to thermoregulation over first year
Cardiovascular System
natal and neonatal teeth may be associated with other anomalies
first primary teeth on average at 6-10 months starting with lower central incisors
average 12-month-old has 6 to 8 teeth
decreased saliva for first 3 months
stomach capacity 0.5-1.0 oz at birth
amylase (carbs) and lipase (fats) deficient until about 5 months mothers should not start cereal until after 5-6months
immature liver - conjugation of bilirubin and medications immature
meconium stools for first few days
formula fed - constipation
newborns 8-10 stools per day
after newborn period formula fed don't stool every day
straining with bowel movement not normal
Gastrointestinal System
more susceptible to dehydration due to increased extracellular fluid
frequent urination
reduced renal perfusion
and reaches full maturity
by 2 years
Genitourinary System
newborn acrocyanosis and mottling is normal
thinner skin leads to increased absorption of topical medications and poorer temperature regulation
Integumentary System
fetal hemaglobin (HbgF) in large amounts at birth - shorter lifespan then HgbA, so increased risk for anemia in first 2-3 months as HbgF replaced by HgbA
Iron storage sufficient for about 6 months if born to a non anemic mom
Premature infants miss maternal transfer of iron during last 3 months
Hematopoietic System
immunity from mom during the first 3-6 months due to IgG transfer
infant production of IgG about 60% at 1 year
IgM production begins at birth with IgA, IgD, and IgE gradually increasing
Immunologic System
Brain 80% of adult size by 3 years
Myelinization complete around 24 months
Neurologic System
alveoli increasing but not adult until 7 years
trachea and airways grow
but relatively small
large tonsils and
short and straight
Eustachian tubes
Respiratory System
Heart rate continues to decrease
BP continues to increase
easy to compress capillaries
Cardiovascular System
stomach increasing in size - 3 meals a day
stool passage decreases in frequency
digestion still not mature
bowel control usually achieved by 3 years
Gastrointestinal System
adult bladder and kidney function by 16-24 months
urinary output 1 mL/kg/hour
decreased urinary frequency due to increased bladder capacity
Genitourinary System
lengthening of bones and strengthening of muscles
pot-bellied look due to weak abdominal muscles
Musculoskeletal System
Organ System

Physical Growth
slower velocity of growth compared with infant
growth is in spurts
average of 3-5 pounds and 3 inches per year
generally 1/2 adult height at 2 years
anterior fontanel should be closed by 18 months
head size more proportional at 3 years
very rapid growth requires close monitoring for signs of abnormality
newborns lose up to 10% body weight
birthweight regained by 10-14 days make sure baby wasn't overloaded (induction, lots of IV fluid)
Infants grow approximately 2.5 cm (1 in) per month the first 6 months of life 1/2 inch for next 6 months
Growth occurs in spurts after the age of 6 months, and the birth length
increases by 50% by the age of 12 months length
head circumference 1 cm > chest at birth
rapid head growth over first year - monitored at each visit
Motor Skill

15 mos walks without help, creeps up stairs
18 mos assumes a standing position
2 years walks up and down steops by placing both feet on each step.
2.5 years jumps in place with both feet, stands on one foot momentarily

Gross Motor
1 mos demostrates head lag
2 mos - lifts head off mattress when prone
3 mos - lifts head and shoulders from prone, slight head lag
4 mos- rolls from back to side
5 mos- rolls from front to back
6 mos- from back to front
7 mos- bears full weight on feet
8 mos- sits unsupported
9 mos - pulls to standing; creeps on hands and knees instead of crawling
10 mos - changes from prone to sitting
11 mos - walks while holding on to something (cruises)
12 mos sits down without assistance
Gross Motor
1 mos- has a grasp reflex 7 mos- transfers objects from hand to hand
2 mos- holds hands open 8 mos- begins using pincer grasp
3 mos- grasp reflex disappears 9 mos- has crude pincer grasp
4 mos- places objects in mouth 10 mos- grasps rattle by handle
5 mos- uses palmar grasp dominantly 11 mos- places objects in container, neat pincer gras
6 mos- holds a bottle 12 mos- tries to build 2 block tower without success

Fine Motor
15 mos- Uses a cup well; builds two block tower
18 mos- uses a spoon turns pages in a book
2 yrs- builds 6-7 block tower
2.5 yrs- draws circles; good hand-finger coordination
Fine Motor
1 month = eats 2-3 oz, every 2-3 hours
2-4 months = eats 3-4 oz every 3-4 hours
4-6 months = eats 4-5 oz, 4 times/day, rice cereal is usually recommended, vegetables are a better choice
6-8 months = eats 6-8 oz, 4 times daily, adds vegetables/yogurt/egg yolk/fruits; begin weaning to cup; may begin juices but unnecessary
8-10 months = eats 6 oz, 4 times daily, adds finger foods, meats an be given, vegetarian diet not recommended before age 2. I do not believe this is evidence based.
10-12 months = eats 6-8 oz, 4 times daily, eats soft table foods feeds self with cup and spoon
Fluid Requirements: Newborn 140-160 mL/kg/day
Infant 100 mL/kg/day for first 10 kg
50 mL/kg/day for next 10 kg
Calorie Requirements: Newborn 105-108 kcal/kg/day
Infant 1-6 months 108 kcal/kg/day
6-12 months 98 kcal/kg/day
Breastmilk and standard formula has 20 kcal/oz
Sensory Development
20/50 to 20/40 vision
same as adult
Taste and Smell
continues to develop, but poor discrimination puts toddler at risk for accidental ingestion
Exploration of the world through the senses is the "work" of the toddler
Newborn: nearsighted, focuses at 8-15" at birth, prefers dark/light contrast
binocular vision by 4 months
full color vision by 7 months
newborn hearing is as acute as adult and prefer parent's voice at birth
can differentiate smells at 1 week
prefers sweet from birth - develops nonsweet taste
may be most important for newborn
Sensorimotor Period (birth to 2 years)
Use of reflexes (birth to 1 month)
sucking, rooting, grasping; use of senses
Primary circular reactions (1 to 4 months)
pleasure gained from a response causes repetition
Secondary circular reactions (4 to 8 months)
beginning of cause and effect
Coordination of secondary schemes ( 8 to 12 months

Nursing application
toys and murals
for interesting
environment and
Cognitive - Piaget
Oral Stage
pleasure largely from mouth
greatest attachment is to mother

Nursing application
pacifier for painful procedures or encourage breastfeeding
Psychosexual - Freud
Trust Vs Mistrust
trust is fostered by basic needs being met
fosters optimism

Nursing application:
hold often, especially after painful procedures
encourage parents to room-in
Psychosocial - Erickson
Sensorimotor (birth to 24 months)
Tertiary circular reactions
(12 to 18 months)
curiosity, experimentation,
Mental combinations (18 to 24 months)
object permanence fully developed
language allows more complex thought
Preoperational (2 to 7 years)
words are symbols
poor logic
Preconceptual stage (2 to 4 years)

Nursing application
name objects and give simple explanations
ensure safe environment
Cognitive - Piaget
Anal Stage (1 to 3 years)
control over body secretions is prime force in behavior

Nursing application
ask about toilet
training being
sensitive to
have potty
chairs available
but do not
begin during
hospitalization or illness
Psychosexual - Freud
Autonomy Vs Shame and Doubt (1 to 3 years)
independence shown through controlling body excretions, saying no, directing motor activity
constant criticism creates shame and doubt in their abilities
important to recognize feelings and needs of others

Nursing application
allow self-feeding and as much self-care as child is capable of doing
Psychosocial - Erickson
Birth-2 months
3-6 months
sounds elicit startle reflex
turns and looks for sounds
prefers human voice
comfort sound with feeding
vocalizes to familiar voice
vocalizes during play & pleasure
laughs aloud
less crying
vowel and consonant sounds
watches speaking mouth
shifts gaze between sounds
understands own name
uses sound to get attention
7-9 months
10-12 months
increases vowels and consonants
uses 2 syllable sounds (dada)
talks along with others
associates words with activity
responds to simple commands
("no no")
understands familiar words
means "mama" and "dada"
repeats sounds made by others
makes intentional gestures
learns 3-5 words
recognizes family member names
recognizes objects by name
understands simple commands
("bye bye")
12-18 months
18-24 months
24-36 months
starts to combine 2 words
mixes real and jargon words/gestures
uses words more than gestures
familiar objects by name
18-22 word vocabulary
refers to self by name
2 and 3 word phrases
articulation lags behind
270-300 word vacabulary
recognizes names of body parts
identifies pictures of familiar
objects when named
follows 2 consecutive related
understands more complex
learns concepts such as hot/cold
listens to and identifies sounds
short complete phrases
inverts subject and verbs
answers simple yes/no questions
uses consonants and pronouns
begins to use ord endings
900 word vocabulary
Developmental Concerns

Should be developmentally appropriate
Play is parallel
Play is solitary

Soft stuffed toys
◯ Teething toys
◯ Nesting toys

Playing pat-a-cake
◯ Playing with balls
◯ Reading books

◯ Brightly colored toys
◯ Playing with block
Filling and emptying containers
Playing with blocks
Looking at books
Push-pull toys
Tossing balls
Finger paints
Large-piece puzzles
Thick crayons
Paraoxysmal abdominal pain and severe, uncontrollable crying
Cries intensely for >3 hours, >3 days/week, >3 weeks/month
Worsens in the late afternoon and early evening
Lift their head, draw their legs up to their tummy, become red in the face, and pass gas
Peak incidence is 6 weeks of age and generally resolve by 3-4 months
Potential causes
Feeding too rapidly, swallowing large amounts of air
Solutions - The 5 S's
Cuddle cure - Swaddle
Put on their side
Make the shhhh sound
Something to suck on
Sudden and unexplained death of an apparently healthy infant aged one month to one year
Peak incidence between 2-4 months of age
Reduce the risk
Back to sleep
No co-bedding
Firm mattress with fitted sheet
No pillows or toys in the bed
Keep crib away from heat vent and set temperature between 68 and 75 degrees
Sudden Infant Death Syndrome - SIDS
Falls -Mobility increases in first year of life, progressing from squirming movements to crawling, rolling and standing Objects are explored by touching and placing in mouth
Burns - Avoid warming formula in a microwave; check
temperature of liquid before feeding.
The temperature of bath water should be checked.
Hot water thermostats should be set at or below
49° C (120° F). Working smoke detectors should be kept in the home.
Handles of pots and pans should be kept turned to the
back of stoves.
Sunscreen should be used when infants are exposed
Electrical outlets should be covered.
to the sun.

Begin at about 1 year of age
Peak around age 2-3 years
Rules of engagement
Stay calm
Separate child from others
Ignore the child but be sure child is safe
Do not bribe, give in, or reward the behavior
Talk calmly to child
Temper Tantrums
need sphincter control
stays dry for at least 2 hours at a time
has regular bowel movements
able to follow simple instructions
uncomfortable with dirty diapers and wanting them to be changed
asks to use the potty chair
asks to wear regular underwear
RELAX! - punishment and coercion can lead to shame and feelings of inferiority
Girls learn around age 2, boys age 3
Toilet Training
Falls - Gross motor skills improve and are able to move chairs to counters and climb up ladders
Poisoning - Gross motor skills enable toddler to get into cabinets
Medicines, cosmetics, and other poisonous substances are easily reached
Burns - Toddler is tall enough to reach stove top
Toddler can walk to fireplace and reach into fire
Toddler can walk onto docks or pool decks
Can stand on or climb seats on boat
Can fall into buckets, toilets, and fish tanks and be unable to get top of body out
Motor vehicle accidents
Toddler is unpredictable
It is recommended to supplement with Vit D. However, if mom is not deficient, breastfeeding and getting the baby into the sun everyday, and using vit D foods like egg yolk, it is unnecessary. African Americans and people who live in Northern latitudes are at risk.
No candy,soda or fast food
No Media: TV, tablets, news programming before
AGE 2 (AAP) I recommend longer.
teeth emerge at 6-10 mos

Choking/suffocation/strangulation/aspiration -Hold the infant for feedings; do not prop bottles.
Small objects that can become lodged in the throat
(grapes, coins, candy) should be avoided.

Clothing should be checked for safety hazards
(loose buttons).
Motor Vehicle Accidents
Infant-only and convertible infant-toddler car seats
are available.
Infants and toddlers remain in a rear-facing car seat
until the age of 2 years or the height recommended by
the manufacturer.
The safest area for infants and children is the backseat
of the car.
Do not place rear-facing car seats in the front seat of
vehicles with passenger airbags.
Infants should not be left in parked cars
Plastic bags should be avoided.
Balloons should be kept away from infants.
Crib mattresses should fit snugly.
Crib slats should be no farther apart than 6 cm (2.375 in).
Crib mobiles and/or crib gyms should be removed by
4 to 5 months of age.
Pillows should be kept out of the crib.
Infants should be placed on their backs for sleep.
Toys with small parts should be kept out of reach.
Drawstrings should be removed from jackets and other clothing
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