Infant Development Milestones

Developmental Care Throughout Childhood

• Infants are newborns through 12 months old, considering NICU age, fresh newborns, and those from obstetrics
• Cephalocaudal pattern describes skill attainment from head to toe, such as holding the head up and head control, with head lag improvement by 4-6 months
• Proximodistal pattern describes skill attainment from trunk out to extremities
• Babies gain gross motor skills before fine motor skills, moving arms before finger control, middle teeth before surround, and gross motor before fine motor

Health Assessment of Newborns and Infants

• Frequent appointments should be scheduled every other week for 2 months
• Appointments are to look for failure to thrive and obvious issues
• The family should be involved
• Use the least invasive approach
• Appointments are conducted at the newborn stage, 1 month, 2 months, 4 months, 6 months, 9 months, and 12 months
• Parents and caregivers should be involved
• Infants should be assessed on the caregiver's lap
• Auscultation should be done first, while the child is quiet or sleeping
• Most invasive procedures should be performed last
• Assess hip dysplasia up to 3 months of age
• Explain everything to caregivers during the assessment

Physical Variants in Newborns and Infants

• Posterior fontanelles are smaller and close between 2 to 3 months
• Anterior fontanelles are larger, closing between 12 and 18 months, which indicates hydration status
• Strabismus is common until 6 months of age
• To inspect the pinna of the ear until 3 years old, pull it back and down
• Diaphragmatic breathing is belly breathing
• Irregular respirations with occasional pauses can occur
• Acrocyanosis may be present
• Heart rate is often irregular
• Asymptomatic murmurs are often present and normal
• Newborns are born with high levels of fetal hemoglobin (HgbF) and experience physiological anemia
• Skin variants include salmon patches and hyperpigmented areas (Mongolian spots)
• Passive immunity lasts until 6 months of age due to the placenta

Reflexes

• Primitive reflexes include sucking, rooting, Babinski, Moro(startle), stepping, palmar grasp, plantar grasp, and tonic neck
• Primitive reflexes are present at birth and typically disappear over the first year of life
• The Babinski reflex normally lasts until 24 months
• Protective reflexes develop after the disappearance of primitive reflexes, are not present until after 12 months of age, and are assessed in toddlers and older children

Pain Assessment of Newborns and Infants

• Assess pain through behaviors, consolability, and caregiver input
• The FLACC scale can be used in disability and high levels of pain
• FLACC (face, legs, activity, cry, consolability) domains are each scored 0 to 2; higher scores indicate more pain (0-10)
• The Neonatal Infant Pain Scale(NIPS) scores facial expression, cry, breathing pattern, arms, legs, and state of arousal
• NIPS is scored 0 to 1 for all except cry, which is scored 0-2; higher score indicates more pain (max 7)

Physical Growth of Newborns and Infants

• There is very rapid growth
• Length grows 1.5 to 2.5 cm per month for the first 6 months, decreasing to 1cm per month for months 6 to 12
• Infants lose 10% of their body weight the first week of life, but it is regained by the end of the 2nd week
• Weight doubles by 4 to 6 months and triples by 12 months. A 7 lb birth weight doubles to 15 lbs by 4 months
• The head circumference increases rapidly the first 6 months then slows until 12 months
• Large head circumference increases risk for hydrocephalus and tumor
• Document all physical growth data points on growth charts to assess trends and averages

Communication and Speech of Newborns and Infants

• Communication occurs through crying, with pitches varying based on different needs
• Infants begin cooing around 2 months, babble by 6 months, and copy sounds at 9 months
• At 12 months, infants say a few words, utilize simple gestures, and follow simple directions

Sensory Development of Newborns and Infants

• There is no color vision until 7 months old and poor vision
• Infants prefer a high pitch and soft touch, with sweet tastes

Social Determinants of Health

• Risks include tobacco exposure, food and housing insecurity, and parental substance abuse
• Protective factors consist of support networks, positive family relationships, and adequate childcare

Infant Behavior & Safety

• Focus on parent-infant relationships and daily routines
• Safety focuses on the home environment and parental knowledge

Immunizations

• Immunizations protect against communicable diseases
• Vaccine information sheets and vaccine administration records should be provided to caregivers
• Types of vaccines include live attenuated, inactivated, toxoid, and conjugate
• Barriers to immunization include lack of transportation, financial concerns, and safety concerns

Nutrition for newborns and infants

• Includes formula versus breast feeding
• Hunger cues include rooting and sucking, crying as a late sign, and moving hands to mouth
• Solid foods should start at 6 months, after the tongue extrusion reflex disappears and the infant can sit in a chair
• Start with iron-fortified cereal and add pureed foods slowly due to allergies

Common newborn and infant conditions

• Colic starts at 6 weeks and resolves at 3–6 months, causing increased fussiness and inconsolable crying, often peaking at 6 weeks and worsening in the evenings. requires caregiver psychological and emotional support; caregivers should lay the infant in the crib when frustrated (no pharm)
• Brief Resolved Unexplained Events(BRUEs) are rare and include cyanosis for than 60 seconds and stopping breathing
• Needs evaluation ASAP (no actual seizure)
• Symptoms include cyanosis or Pallor, slowed or absent breathing, hypertonia or hypotonia, and altered responsiveness
• Episodes last less than 60 seconds and needs to be evaluated by a healthcare provider
• High risk for additional episodes when less than 2 months of age, history of prematurity, or history of more than one BRUE
• Diaper dermatitis is any skin breakdown in the diaper region
• Treat this painful condition by leaving diapers off and allowing skin to dry
• Commercial barriers can be used and notify provider with odor, fever or purulent drainage
• Fever is temp over 38C, 100.4F and is a late sign of infection
• Normal HR is 110-160 and BP is 70/40ish

Health Assessment of Toddlers

• Toddler stage is 1-3 years old and involves play
• Office visits are less frequent than during infancy
• Incorporate flexibility and play, allowing the toddler to touch safe medical equipment like a stethoscope
• Giving choices instead of asking permission and use positive reinforcement and praise
• Use least to most invasive approach, not head to toe, observing RR, WOB, last- checking ears
• Visits occur at 15 months, 18 months, 2 years, 2.5 years and 3 years
• Be flexible during assessment and gather information through play
• Provide distractions, allow toddler to touch safe medical equipment, do not ask permission and use positive reinforcement
• Invasive procedures go last and explain procedures in simple, concrete and positive terms

Physical Variants in Toddlers

• The toddler stage is 12 to 36 months, or 2-3 y.o
• Hand preference develops as 2-3 years
• They use diaphragmatic breathing
• Blood pressure increases as heart rate decreases MORE PUMP, MORE EFFICIENT HR as child gets older
• Stool frequency decreases to usually once per day
• There will be a protruding abdomen
• VS are like adults 12-14

Pain Assessment of Toddlers

• Assess pain through valid and reliable pain scales
• Incorporate caregiver input
• FLACC scale is used (face, legs, activity, cry, consolability), each domain is scored 0 to 2
• Scores of 0 - 10 with a higher score indicating more pain

Physical Growth of Toddlers

• Height measure standing height at 3 years
• Perform sitting weight until 3 years of age
• Weight gain = 5lbs per year
• Head Circumference increases by 2 cm from 12 to 24 mo
• Document all physical growth data points on growth charts to assess trends and averages

Gross Motor Development of Toddlers

• 15 months: Squats to pick up objects, Crawls up steps and Drinks from a cup
• 18 months: Walks independently and Pushes and pulls toys when walking
• 24 months: Runs, Kicks a ball, Jumps with 2 feet and Climbs on furniture
• 36 months: Pedals a tricycle, Jumps forward, Walks up and down stairs with one foot on each step

Communication and Speech of Toddlers

• Receptive language develops before expressive language
• Can understand directions before giving directions
• Encourage caregivers to read to their children
• Read one book per day to assist development

Safety Considerations for Toddlers

• High risk of injury: -Burns: Keep hot objects away and lower hot water heater to 120 -Falls: Prevent climbing, supervise stairs, install gates at the bottom of stairs -Vehicles: Use a forward-facing 5-point harness from 2-4 years of age

Play Considerations for Toddlers

• Parallel play (playing alongside one another but not with each other)
• Short attention spans, do not understand sharing
• Use toys to develop gross motor, fine motor and socials skills: Push/pull toys, tunnels, stackable blocks and puzzles with large pieces, household objects that can be used to make noise
• Musical instruments/active play outside are all popular options

Sleep Considerations for Toddlers

• Needed for G&D and cognitive functioning
• Negative consequences of lack of sleep: mood disturbances, poor behavior, and hyperactivity
• Requirement: 11 to 13 hours of sleep in a 24-hour period
• Typical schedule:
  • 9 hours/night/2 naps until 18 months
  • 9 hours/ night and 1 longer nap after 18 months
• Incorporate consistent bedtime routines

Toilet Training

• Begins around 2 years of age
• Signs of readiness include: remaining dry for 2 hours at a time, having words for urine and stool, bringing a clean diaper to a parent to be changed, and voicing discontent with soiled diapers
• Praise and encouragement for successes are the way
• Stickers and “big kid” underwear can be helpful
• Do not punish for accidents

Temper Tantrums

• Result of receptive language development versus expressive language development
• Can begin at 12 months of age and typically occur from 2 to 3 years
• Frustrating for caregivers
• Reward good behavior and ignore unwanted behavior
• Biting and hitting: Time-outs
• Disruption and inconsistent expectations = increased tantrums

Atopic Dermatitis

• Also known as eczema
• The most common chronic skin condition in children
• More likely to have allergies and asthma
• S/s: severely dry skin, erythematous patches, extreme pruritus, thickening of the skin
• Tx identification and avoidance of triggers, keep skin hydrated and topical corticosteroids if environmental changes are not effective

Acute Otitis Media

• Also known as Ear Infections (Inflammation of the middle ear and middle ear effusion)
• Toddler at risk for speech delay if frequent or untreated
• Risk Factors: Exposure to tobacco smoke, Exposure to other children and Congenital anomalies
• Protective Factors: Breastfeeding & Pneumococcal vaccination
• Tx: Treat with antibiotics and comfort measures
• Myringotomy- put a slit in ear canal- if recurrent AOM

General Information on Preschoolers

• From 3 to 6 years of age
• Gross motor skills become more coordinated and fine motor exponentially
• Preschoolers take initiative and creativity

Health Assessment of Preschoolers

• Begin to involve child in health history and give choices throughout examination
• Use the safe medical equipment for play and perform most invasive parts last
• Visual acuity testing at age 4 and Assess hearing with optoacoustic emissions test
• Can use radial pulses for heart rate assessments

Physical Variants in Preschoolers

• Visual acuity reaches 20/20 at 4 to 5 years of age
• Thoracic breathing begins at age 5 (chest instead of belly)
• daytime control around 3-4 years and nighttime control around 4-5 years old
• Genu valgum (knock-knees) in early preschool period

Pain Assessment of Pre-Schoolers

• May be shy and refuse to talk
• However they are Able to point to the location of pain
• Not able to describe the quality of pain
• Able to use developmentally-appropriate self-report tools
• FACES scale: or FLAC is used with Six cartoon faces with different expressions
• Scale of 0 to 10, with higher number more pain
• Also use observation and caregiver report to assess pain

Physical Growth of Preschoolers

• Height: Grow 2.5 to 3 in (6.1 to 7.6 cm) per year
• Average 4-year old is 40 in
• Weight Gain 5 lb (2.3 kg) per year from ages 3 to 6
• Average 4-year-old weighs 40 lb (18.1 kg)
• Head Circumference slower - Only 1.9 to 2.4 in (5 to 6 cm) increase

Gross Motor Development of Preschoolers

• 3 years: Walks up and down stairs with one foot on each step, Pedals a tricycle, Runs well and Jumps forward
• 4 years: Climbs and hops, Stands on one foot and a Catches a bounced ball
• 5 years: Swings, Climbs, Stands on one foot for 10 seconds and Somersaults

Communication and Speech of Preschoolers

• Rapid language acquisition- Uses concrete language
• Language is learned through exposure to words
• Children living in poverty are at increased risk of language delay
• Screen for language delays at each well-child visit
• Autism, Cognitive impairment, Emotional delays, Low socioeconomic status and Underlying neurological disorders are included in underlying causes of language delay

Social and Emotional Development of Preschoolers

• Learn to cope with emotions
• Use imaginary play and imaginary friends to explore communication and emotions
• Interested in basic sexuality by the age of 5 to 6
• Develop their own identity and independence
• Cooperation is more common
• Learn to share and take turns

Safety Considerations for Preschoolers

• Like new experiences
• Role model safe behaviors
• Stranger and street safety are most important
• Teach home address and phone number
• Natural curiosity can create harmful situations such as- Improper handling of firearms, Poisoning and Choking

Play Considerations for Preschoolers

• Engage in imaginary and creative play and allow to work thru frustration and anxiety
• Use arts and crafts for fine motor skills: clay and crayons
• Learn to share and take turns: Simple board games
• Outdoor activities: Playgrounds, bicycles, tricycles & unstructured physical activity
• Avoid toys with small parts, small magnets, or lead paint And Excessive electronics

Sleep Considerations for Preschoolers

• Usually stop napping
• Hours of sleep are consolidated into one long block (10-13 hours of sleep)
• Establish bedtime routines and remain consistent
• Nightmares: Waking up and scared, wants comfort from parents
• Night Terrors: Not awake and doesn't remember episodes. Thrashes screams and Do not wake the child

Nutrition for Preschoolers

• Well rounded diet avoiding high fat and sugar foods
• 3 meals and 1-2 snacks
• Avoid foods high in fat and sugar
• Involve child in meal prep and offer choices when possible
• Do not force a child to eat and Do not fix separate meals which encourages picky eating

Fifth's Disease

• (slapped cheek disease) is also known as erythema infectiosum (caused by parvovirus B19 and is viral)
• Peaks in late winter/spring
• Bright red cheeks with “slapped" appearance and lacy rash on trunk and upper extremities
• Benign and self-limiting (offer supportive treatment- Avoid in pregnant women)

Hand-Foot-and-Mouth Disease

• Caused by coxsackie virus
• Spread through fecal-oral route (prevention= hand washing)
• Manifestations Vesicular and/or pustular lesions occur on the oropharynx, palms of hands, and soles of feet
• May have mild fever and moderate pain and is self-limiting in about 1 week
• Supportive care, hydration and Symptomatic Management is important

Conjunctivitis

• inflammation of conjunctiva- "pink-eye"
• Bacteria, viral or allergies (Associated with thick drainage, pruritus and /or vision changes)
• Very Contagious Viral is self-limiting (TX- antibiotics Symptomatic and antihistamines)

School-Age Child

• Ages are 6-12 years old
• Maturity increases and they are more coordinated
• Logical Thinking And Friends are very important
• Development of Self confidence & sports

School-age Child Health Assessment

• Annual health promotion visits between 6 and 12
• Direct questions to child but verify with caregiver
• Assess development and nutrition
• Perform examination in a head-to-toe manner, explain
• Snellen chart to test vision
• Parents should remain in examination room
• Hyperlipidemia screening begins at 11 years old
• Least invasive first (Check up and Hospitals)
• Fully developed respiratory system @10 years old

School-Age Physical Variants

• Oriented to person, place and time
• Bowel movements affected by diet and physical activity
• May see acne and legs and arms grow faster than the rest of the body

School aged Puberty

• Monitor for precocious puberty
• Males- Testicular enlargement 9-14 years
• Females Breast Development, 8-13 years old- Menarche occurs 2 years after breast

School-Age Pain Assessment

• Numerical Rating Scale for older than 7
• Straight line with number spacing (0-10) More indicates more pain
• ask questions to determine pain quality
• Nonpharmacological Pain Methods work well and include cultural considerations in pain assessment

School-Age Growth

• height: 2.5-3 in yearly
• Intermittent growth spurts (girls taller than boys at 12)
• weight: 6.5-7.5 lb yearly (varies)
• Begin plotting body mass index to determine risk for obesity

School Age Motor Development

• gross motor: improves and they can ride bike by age 7-8
• fine motor- improved dexterity and hand coordination
• May become frustrated as skills develop

School-Age Communication development

• Metalinguistic awareness which means to think about language /humor
• Increase thinking skills and able to talk through thoughts

School- age social/emotional development

• separate from parents and gain relationships
• develop positive and negative self-esteem thru interactions with others
• Children identify a best friend by age 7
• peer pressure begins

School-Age Gender dysphoria

• Identifying with a gender different from biological sex
• First seen in children ages 9 to 10 years old
• May be short-term or long-term
• Watch for signs of bullying, depression, anxiety, and low self-esteem

School-Age Safety considerations

• Sports: wear gear and dehydration
• Water: never allow children to swim alone and teach to swim
• Bicycle: Wear helmet (Fits)
• Pedestrian: Look both ways before crossing
• Home: store firearms and develop fire safety plan

School-Age Sleep

• Require 9 -12 hrs of sleep per night (Adequate sleep= Healthy immune system, improved academic performance, overall better mood and improved behavior
• Encourage healthy bedtime routines- such as consistent bedtime, no electronics and activity

School Refusal

• Unwillingness to attend school (bullying, test taking anxiety)
• start a journal with the family
• Multiple short absences or one prolonged absence
• Common in children ages 5 to 7 and 12 to 14
• Vague somatic symptoms

Bullying

• Common for children
• Common in school verbal and social
• Bullying is associated with many negative consequences such as-Depression, anxiety and Struggles
• Report bullying behavior to the school

Pharyngitis and Tonsillitis

• Viral or Bacterial
• Sore throat is most common symptom
• Streptococcal pharyngitis presents with sandpaper-like rash- TREAT WITH ANTIBIOTICS
• Tonsillitis likely to be viral and Tonsillar hypertrophy may lead to partial airway obstruction /sleep apnea

Care of the Adolescent

• Occurs during ages 10-21 years old
• Divided into three Stages defined by Age - Early 10-13yo -Middle 14-17yo -late 18-21 years
• Increased risk-taking behaviors AND Ongoing identity formation occur (-IDENTITY V ROLE CONFUSION - Good VS bad)

Health Assessment of Adolescents

• Annual Health Promotion
• PRIVACY is important
• Health history without caregiver present while allowing caregiver to ask questions
• Head to toe assessment while keeping body covered - Drugs, alcohol, marijuana, and sequential

Adolescents physical variants

• Wisdom teeth develop while Prefrontal cortex is undeveloped until late Adolescence
• Onset of puberty occurs and muscle Development is greater in males
• Active sebaceous glands can lead to acne and skeletal growth occurs before muscle growth

Adolescents Pain Assessment

• Numerical Rating Scale - Straight line with evenly numbered spaces - Scale of 0-10 ( Higher = More pain)
• Cognitive interventions (Use deep breathing, mindfulness, and cultural consideration)

Adolescents Physical Growth

• Varies based on age and gender
• Females grow 3-3.5 inches and Male 3.5-4 Inches Yearly during growth spurt
• Healthy BMI is 5-85 Percentile where Body fat increases in girls & increased in boys

Adolescents language

• Vocabulary increase with abstract thinking and Language is adult at end of adolescence

Adolescents Social and emotional development

• Peers become most important along separation from parents and strive for independence
• Self-concept and body image are closely related

Adolescents Safety Recommendations

• Motor Vehicle = Seatbelt, Avoid Distractive Driving
• Fire = Safe Around Fire
• Sun = Sunscreen

Adolescents risk Reduction

• Safe Sex practice
• Substance use is risky along with deficits!
• Provide education and determine risk for SUD

Adolescents Sleep Consideration

• Need 7-8 hr a night
• Circadian Rhythm Happens( School start before 9am)
• Sleep deficts (Mood Changes, Substance Use, obesity)

More adolescent considerations

• Violence (Physical,Verbal,Sexual)
• Depression(Lasts 2 weeks treat as therapy/SSRI)
• Infectious mononucleosis (Epstein Barr Virus - Fatigue, enlarged tonsils)
• Dysmenorrhea (painful periods- Use NSAIDS, contraception)

Test your knowledge of infant reflexes, growth patterns, communication, and sensory milestones. This quiz reviews the key stages of development, including motor skills and the influence of social determinants of health.