Developmental Management of Infants PDF

1 Developmental Management of Infants  Rapid, predictable, unique, challenging change between months 1-12 of life  Routine care by PCP of infants/families:  Assess/monitor growth & development  Educate parents about child de...

1 Developmental Management of Infants  Rapid, predictable, unique, challenging change between months 1-12 of life  Routine care by PCP of infants/families:  Assess/monitor growth & development  Educate parents about child development  Collaborate with other health professionals  Foster healthy growth & development  Identify/manage health problems  Guide, counsel, support parents in health/illness Copyright © 2021 by Elsevier, Inc. All rights reserved.  2 Infant Mortality (1 of 2)  Infant mortality rate declined over past decade  Declined 15%  Rate highest in mothers less than 20 years or older than 40 years  Inequities between non-Hispanic blacks, Native Americans and the non-Hispanic white population persist  non-Hispanic blacks have double the mortality rate of non-Hispanic white women Copyright © 2021 by Elsevier, Inc. All rights reserved.  3 Infant Mortality (2 of 2)  Leading causes:  Accidents are the leading cause of death in infants  Congenital malformations  Low birth weight  Prematurity  Maternal delivery complications  Sudden infant death syndrome (SIDS)  Unintentional injuries  Of these five leading causes, four declined, but deaths due to unintentional injuries increased by 11%. Copyright © 2021 by Elsevier, Inc. All rights reserved. Growth 1 of 4 4  Weight  By year 1 infant should triple birth weight (21.5 lbs by year 1).  Height  Infant length increases an average 1 in a month during first 6 months and slows over the next 6 months. Average is 29 inches by Year 1.  Head Circumference  Growth is rapid during first 6 months; 33% increase from birth (08 in by Year 1)  Cranial sutures close – posterior fontanel at 6-8 weeks; anterior fontanel 12-18 months; Brain increases 2.5 times by 1 year  Chest Circumference  Smaller than head circumference at birth; equal by 1 year; lateral diameter greater than anteroposterior Copyright © 2021 by Elsevier, Inc. All rights reserved. Growth 2 of 4 5  Vital Signs  Respiratory rate slows to 30 to 50 breaths per minute  Uses diaphragm to breathe but abdominal respiratory movements are normal.  Heart rate is 80 to 160 beats per minutes.  Sinus arrhythmias are common  increased heart rates during inspiration and decreasing rates with expiration.  Diastolic pressure decreases  Fluctuations in blood pressure can be observed during the various states of activity and emotions. Copyright © 2021 by Elsevier, Inc. All rights reserved. Growth 3 of 4 6  Body Systems  Significant maturation of all body systems between 1 and 12 months of age  Neurologic and musculoskeletal maturation result in the development of purposive movements and initial speech  High percentage of extracellular fluid  predisposing them to fluid loss and dehydration.  Additional risk of dehydration and electrolyte imbalance  Diastolic pressure decreases Copyright © 2021 by Elsevier, Inc. All rights reserved. Growth 4 of 4 7  A significant amount of maternal immunoglobulin G (IgG)  provides immunity for approximately three months post-delivery  infant’s inability to optimally respond to infectious bacteria and viruses is affected.  The levels of IgA, IgD, and IgE are reduced and do not mature until after infancy.  Digestive system is immature with decreased enzymatic activity  Drooling becomes prominent due to the poor coordination of the swallow reflex  Digestion is affected by deficiency in several gastric components  Stomach size increases to accommodate 3 meals and three snacks daily. Copyright © 2021 by Elsevier, Inc. All rights reserved.  8 Development of Infants: 1 to 3 Months (1 of 3)  Physical Development  Length increases 1.4 inches/month (3.5 cm)  Weight increases 0.5 to 1 ounce/day (14-28 grams)  Eats 8-10 times each 24 hours  Growth spurt at 6 to 8 weeks may cause fussiness, increased frequency of feedings  Elimination patterns more regular (1-2 daily); wet diaper after each feeding  Sleep cycles more regular/well-defined patterns (15-16 hours daily)  Fussy periods from 1 to 3 months Copyright © 2021 by Elsevier, Inc. All rights reserved.  9 Development of Infants: 1 to 3 Months (2 of 3)  Motor Skills Development  Fine motor skills – attempt to grasp objects  Visible head control – lift head 45 degrees  Normal body movements symmetric  Landau reflex emerges by three months  Communication and Language Development  Connection with parents  Cooing/babbling sounds  Nonverbal still primary form of communication Copyright © 2021 by Elsevier, Inc. All rights reserved.  10 Development of Infants: 1 to 3 Months (3 of 3)  Social and Emotional Development  Imitate parents’ expressions  Social smile by 3 months  Parents may misinterpret increased activity as need for more stimulation  Cognitive Development  Visually track faces, toys  Facial expressions  Respond to sounds  Show excitement when toys are in view Copyright © 2021 by Elsevier, Inc. All rights reserved.  11 Copyright © 2021 by Elsevier, Inc. All rights reserved.  12 Development of Infants: 4 to 5 Months (1 of 2)  Physical Development  Regular sleep, eating, playing patterns  Begin to sleep through night  Double birth weight by 4 to 6 months  Motor Skills Development  Play with hands/reach for objects  Primitive reflexes begin to disappear  Roll front to back, then back to front  Learn to sit – tripod position and then erect  Bear full weight when standing – love to bounce Copyright © 2021 by Elsevier, Inc. All rights reserved.  13 Development of Infants: 4 to 5 Months (2 of 2)  Communication and Language Development  Babble, coo, laugh  Search for sounds  Oral motor development more complex  Social and Emotional Development  Spontaneous smile  Interact with parents  Cognitive Development  Visual exploration  Mouthing behaviors Copyright © 2021 by Elsevier, Inc. All rights reserved.  14 Copyright © 2021 by Elsevier, Inc. All rights reserved.  15 Development of Infants: 6 to 8 Months (1 of 2)  Physical Development  Solids added to diet; weight velocity slows  Teething symptoms  Sleep routine disrupted  Motor Skills Development  Sit, scoot, crawl  Rake objects, then use pincer grasp  Transfer objects from one hand to another Copyright © 2021 by Elsevier, Inc. All rights reserved.  16 Development of Infants: 6 to 8 Months (2 of 2)  Communication and Language Development  Vocalizations increase in pitch/tone  Specific sound imitation/use of consonants  Receptive language skills increase  Social and Emotional Development  Enjoy social play  Use of gestures  Stranger/separation anxiety  Cognitive Development  Cause and effect  Beginning object permanence Copyright © 2021 by Elsevier, Inc. All rights reserved.  17 Copyright © 2021 by Elsevier, Inc. All rights reserved.  18 Development of Infants: 9 to 12 Months (1 of 3)  Physical Development  Growth spurts with periods of slowed growth  Regular bowel/bladder patterns  Demonstrate specific food preferences  Motor Skills Development  Hold and play with objects  Sit for long periods, crawl on hands and knees  Begin to stand and walk Copyright © 2021 by Elsevier, Inc. All rights reserved.  19 Development of Infants: 9 to 12 Months (2 of 3)  Communication and Language Development  Play pat-a-cake and peek-a-boo  Enjoy songs/rhythms  3 to 4 words  Name pictures in book, look for objects when named, follow one-step requests  Social and Emotional Development  Stranger anxiety/fear of new situations  Emotions develop – affection, anger, jealousy  Love to master skills Copyright © 2021 by Elsevier, Inc. All rights reserved.  20 Development of Infants: 9 to 12 Months (3 of 3)  Cognitive Development  Complete more complicated tasks  Begin to draw with crayon  Play more spontaneous/self-directed Copyright © 2021 by Elsevier, Inc. All rights reserved.  21 Copyright © 2021 by Elsevier, Inc. All rights reserved.  22 Copyright © 2021 by Elsevier, Inc. All rights reserved.  23 Developmental Assessment of Infants  Monitoring of growth & development critical because of rapid changes in infancy  Consistent visits with same provider important  Screening strategies for infants (Table 10.2)  Standardized instruments at 2-, 4-, 6-, 9-, 12-month well- child visits  Ages & Stages Questionnaire (ASQ)  Parents’ Evaluation of Developmental Status (PEDS)  Other tools for specific areas of concern  RED FLAG: refer for further screening if delays Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 24 Infants (1 of 13)  Education/guidance to address common issues  Goals of anticipatory guidance:  Develop skills to use as child grows  Understand development/capabilities  Appreciate own child’s abilities  Interact with child to strengthen bond, nurture child, increase parental confidence Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 25 Infants (2 of 13)  The Prenatal Visit  Provides foundation/establishes provider as resource for later visits  Breastfeeding, immunizations, circumcision, injury prevention, safe sleep, car seats  Family adjustments/siblings  Family history  The Neonatal Visit  Family readiness, infant behaviors  Feeding, safety, routine care  Information in writing/appointment for follow-up visit Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 26 Infants (3 of 13)  Birth to 1 Month  Regulation and sleep-wake patterns  16 hours of sleep/day  Consistent daily routine to develop day-night cycles  Variety of movement, touch to help to wake state  Use of music, voice to help with self-regulation  Strength and motor coordination  Supine for sleep with “tummy time” when awake  Feeding and self-care  Suck-swallow/breathing rhythms  Weight gain, urine output  Support/guidance for breastfeeding Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 27 Infants (4 of 13)  Birth to 1 Month (Cont.)  Communication and language  Nonverbal communication  Attend promptly to crying to develop trust  Imitation of sounds to encourage vocalization  Social and emotional growth  Social interactions while alert  Gentle touch and holding  Family issues/parental roles  Cognitive and environmental stimulation  Encourage looking, hearing Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 28 Infants (5 of 13)  1 Through 3 Months  Regulation and sleep-wake patterns  Structuring day  Immature nervous system – needs swaddling  Sleep location, safety, naptime/nighttime rituals  Self-soothing  Strength and motor coordination  Place in different positions to encourage movement  Feeding and self-care  Feedings more consistent, increased non-nutritive sucking  Feedings meet nutritional/developmental needs  Use of cues for readiness to eat/satiation  Encourage continued breastfeeding Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 29 Infants (6 of 13)  1 Through 3 Months (Cont.)  Communication and language  Encourage talking/singing  Understanding infant’s cues  Reading as part of routine  Social and emotional growth  Hands as “toys” and for self-soothing/exploration  Respond to cries to reassure that needs are met  Temperaments expressed in behaviors  Increased need to socialize/play  Cognitive and environmental stimulation  Increased visual acuity  Toys/equipment should be safe/developmentally appropriate Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 30 Infants (7 of 13)  4 Through 5 Months  Regulation and sleep-wake patterns  Allow to self-soothe  Nighttime rituals important  Temperaments emerging  Strength and motor coordination  Increased mobility increases safety concerns  Floor-time play to encourage motor strength and coordination  Feeding and self-care  Drooling from salivary gland maturation  Readiness for solids based on GI tract/developmental maturity  Spoons and “finger foods” may be introduced  Interact during feeding to increase socialization Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 31 Infants  4 Through 5 Months (Cont.) (8 of 13)  Communication and language  Reciprocal talking helps develop communication skills  Talking during caregiving holds infant’s attention  Reading is beneficial  Social and emotional growth  Non-nutritive sucking  Discuss/differentiate discipline/punishment  Information about developmental milestones  Parental roles/parent time  Safe and appropriate child care  Cognitive and environmental stimulation  Increased activity increases need for attention/play  Mirror on changing table  Walks in park, visits to neighbors, trips to grocery store Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 32 Infants (9 of 13)  6 Through 8 Months  Regulation and sleep-wake patterns  Can go 6-12 hours without eating  Teething may disrupt sleep  Teaching to sleep in crib  Strength and motor coordination  Floor time to encourage crawling/walking  Childproofing home, poison control center  Bathwater temperature, hot water heater temperature  Feeding and self-care  Solids by 6 months/iron-fortified foods if breastfed  Structured mealtimes  Allow self-feeding with spoon/cup Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 33 Infants (10 of 13)  6 Through 8 Months (Cont.)  Communication and language  Use names of objects, respond to vocalizations  Read to infant, show picture books  Name body parts  Social and emotional growth  Encourage “transitional object” in anticipation of separation anxiety  Discuss limit-setting, discipline, positive attention  Cognitive and environmental stimulation  Toys involving cause-and-effect reactions  Common household objects as toys  Interactive games Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 34 Infants (11 of 13)  9 Through 12 Months  Regulation and sleep-wake patterns  Transitional object to ease new experiences  Predictability in daily schedule  Temperament more evident  Strength and motor coordination  Positive reinforcement for new motor skills  Childproofing environment is critical  Safe storage of purses, medicines  Bathwater temperature  Plastic bags, balloons, small objects out of reach  Oral exploration increases – poison control number  Active supervision always  Outings for parents/child Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 35 Infants (12 of 13)  9 Through 12 Months (Cont.)  Feeding and self-care  Parents provide healthy foods/infants determine how much they eat  Dental hygiene and caries/fluoride supplements  Blended foods, finger foods, soft solids  Practicing with spoons/cups – wean from bottle/pacifier by 12 months  Consistent mealtimes and snack times  Family mealtimes at least once daily  Communication and language  Reinforce infant’s efforts to communicate  Name utensils/colors, smells, tastes of food  Name body parts  Reading more interactive Copyright © 2021 by Elsevier, Inc. All rights reserved.  Developmental Assessment of 36 Infants (13 of 13)  9 Through 12 Months (Cont.)  Social and emotional growth  Emerging desire for autonomy  Discipline as a guidance process  Distraction effective to redirect infant  Stranger anxiety/separation rituals  Parents need increased energy/coping skills/reinforcement of their own skills  Cognitive and environmental stimulation  Allow child to take lead in play  Interactive games to encourage reciprocal social play  Books, music, blocks, stacking toys for self-initiated play  Bath time, water tables, sandboxes to encourage messy play and tactile stimulation Copyright © 2021 by Elsevier, Inc. All rights reserved.  37 Common Developmental Issues for Infants and Families  Sleep  Varies widely from birth to 12 months  Nutrition  Nutrition/breastfeeding guidelines  Assess concerns by observation, feeding history  Crying Table 10.3  Address normal crying patterns  PURPLE crying to help explain normal patterns  Postpartum depression  “Baby blues” normal; occur in 60% to 80% of new mothers  Postpartum depression 1-4 weeks after delivery or anytime during first year  Edinburgh Postnatal Depression Scale (EPDS) Copyright © 2021 by Elsevier, Inc. All rights reserved.  38 Copyright © 2021 by Elsevier, Inc. All rights reserved.  39 Red Flags for Infant Development  Motor problems such as cerebral palsy  Communication problems  Cognitive problems  Processing disorders (deafness/blindness)  Central processing disorders (motor, language, perceptual dysfunction)  Behavioral problems  Degenerative disorders Copyright © 2021 by Elsevier, Inc. All rights reserved.  40 Red Flags for Infant Development: Specific Risk Factors for Delays  Prenatal exposure to street  Endocrine and metabolic drugs/alcohol problems  Prematurity  Genetic syndromes  Low birth weight, SGA, IUGR  Failure to thrive  Anoxia or birth trauma  Cerebral palsy  Neonatal intensive  Sensory problems care/long-term  Parental or environmental hospitalization deficit in meeting needs of  Cardiovascular illness infant Copyright © 2021 by Elsevier, Inc. All rights reserved.  41 Red Flags for Infant Development  Potential problems need close surveillance  Referrals necessary when clear indicators present  RED FLAG: referral to behavioral or developmental specialist if autism suspected  See Table 10-4 for specific red flags Copyright © 2021 by Elsevier, Inc. All rights reserved.  42 Copyright © 2021 by Elsevier, Inc. All rights reserved.  43 Discussion Questions 1. Many providers are required to see 25 to 30 patients per day in their primary care practice. Discuss ways providers assess parents’ sleep needs, expectations regarding crying, and maternal depression while providing education about infant sleep-wake states, feeding patterns, and emotional development during a 15- to 20-minute newborn examination. 2. Identify developmental behaviors of a 6-month-old infant that would require an in-depth assessment and referral for developmental evaluation. How would your answer be different if the infant were 2 months old? Nine months old? Copyright © 2021 by Elsevier, Inc. All rights reserved.  44 Discussion Questions (Cont.) 3. You get a phone call from the mother of a 10-day-old infant who tells you her son is crying “all the time.” Further questioning reveals he wants to breastfeed every 3 hours (up from every 3½ to 4), and he has four or five loose bowel movements (BMs) daily that “look like they have birdseed in them.” The mother denies any yellowing of the skin or sclera. Crying episodes last about 3 to 4 minutes at a time, and he quiets when the parent holds or swaddles him. What is the best response to this parent? What additional subjective or objective information do you need? What guidelines for management and follow-up will you use? 4. Create a caregiver education sheet that includes anticipatory guidance for one of the recommended infant well visits. Be sure to provide information regarding development, developmental red flags, nutrition, sleep, and safety. This handout should be written for caregivers and not health care professionals. Copyright © 2021 by Elsevier, Inc. All rights reserved.