Growth and Development PDF

Growth and Development LESSON 1 Stage Age period Neonate first 28 days of life Infant 1 month – 1 year Toddler 1-3 years Preschooler 3-5 School age 6-12 Adolescent 13-17 Late adolesce...

Growth and Development LESSON 1 Stage Age period Neonate first 28 days of life Infant 1 month – 1 year Toddler 1-3 years Preschooler 3-5 School age 6-12 Adolescent 13-17 Late adolescent 18-21 1  Growth and Development 20XX 2 Children progress through predictable stages of growth and development - Both processes highly depend on genetic, nutritional, and environmental factors. GROWTH - increase in physical size (height, weight, head circumference (measured until 2 years old) = anthropometrics DEVELOPMENT - Increase in skills, ability to function (qualitative change) - ability to perform specific task - MATURATION is synonymous with development 2  Growth and Development 20XX ntation title 3 PARAMETERS: AREAS TO ASSESS Gross motor - controlling the head, sitting, crawling, maybe even starting to walk (big muscle groups) Fine motor - holding a spoon, picking up a piece of cereal between thumb and finger (dexterity of the fingers, hand coordination) Small muscle group = intricate movements Sensory - seeing, hearing, tasting, touching, and smelling Language - starting to make sounds, learning some words, understanding what people say (able to communicate), means to express feelings and needs Social - the ability to play with family members and other children, interaction with the others Babies do not develop at the same rate. There is a wide range of what is considered "normal." Your baby may be ahead in some areas and slightly behind in others. If you are worried about possible delays, talk to your baby's healthcare provider. 3  Principles of Growth and Development Growth and development are continuous processes from conception until death. Growth and development proceed in an orderly sequence. Different children pass through the predictable stages at different rates. All body systems do not develop at the same rate Developmental is cephalocaudal. Development proceeds from proximal to distal body parts. There is an optimum time for initiation of experiences or learning Development proceeds from gross to refined skills. Neonatal reflexes must be lost before development can proceed. 20XX A great deal of skill andpresentation behavior title is learned by practice 4 10 PRINCIPLES OF GROWTH AND DEVELOPMENT 1. You grow and mature until you die 2. Learn to walk before u run 3. Range/period when you can achieve a certain milestone: on the average time to walk @ 12 months, others will be able @ 15 mos. 4. CNS (brain) develops quickly/faster than development of the musculoskeletal system - brain development is complete at age 10, while bone continue to develop until epiphyseal growth plate closes @ 13-16 yrs. 5. Head to toe: head control @ 2 mos, walking @ 12 mos 6. Rolling (trunk) and crawling (trunk and extremities) 7-10: 4  Factors Influencing Growth and Development 20XX presentation title 5 Genetics - genetic makeup of individual, DNA, runs in the family Gender - on average : female are born weighing less and shorter than male - male keep height/weight comparison until prepuberty - puberty : female begins growth spurt (typically 6 month to 1 year earlier than male - end of puberty: males tend to be taller and heavier Health environment - poverty, exposed to a cluster of health determinants that results in high infant mortality, developmental delays, abuse, obesity Nutrition - plays vital role in the body ability to resist infection - differences in recommended calorie intake for male and female starts at 9 year old - male @ 18 year : 2400, female: 1800 Intelligence - associated with genetics 5 - 5  THEORIES OF CHILD DEVELOPMENT 20XX presentation title 6 Developmental theories - provides road maps for explaining human development - assessment : attainment of developmental skills Developmental skills - skills or growth responsibility arising at particular time in an individual’s life - achievement of which provides a foundation for the accomplishment of future tasks Freud’s psychosexual theory - based on observation of adult experiencing mental disturbance - described adult behavior as being result of instinctual drives of a primarily sexual nature (libido) - source of sexual pleasure or gratification = comes focused on a particular body parts at each stage Erickson’s theory (psychosocial development) - stresses the importance of culture and society in development of personality 6  - looks at action that leads to mental illness - each stage has 2 opposing forces : fulfill a certain task successfully Piaget theory of cognitive development - way children learn and think - 4 stages of cognitive development Kohlberg theory of moral development - based on Piaget theories, the way children gain knowledge of right and wrong reasoning (MORALITY) Fowler’s : spiritual development - has 6 stages 6  20XX presentation title 7 Freud’s Psychosexual theory 7 20XX presentation title 8 8  20XX presentation title 9 Erickson’s Psychosocial Infancy : Trust vs. mistrust Toddler: autonomy vs, shame and doubt Preschool : initiative vs. guilt School : industry vs. Inferiority Adolescent (early) : Identity vs, role confusion Adolescent (late) : Intimacy vs. isolation 9  20XX presentation title 10 Piaget’s cognitive development 4 stages 1. sensorimotor- 0-2 - understanding – coordinating sensory experiences with physical actions (sensory= love/trust ---- motor= sucking) – satisfied if someone is giving what he needs - reflexive/instinctual (birth) to symbolic thoughts 2. Preoperational – 2-7 - represent words with words and images - symbolic thinking (language and images) - goes beyond sensory and physical actions – Language and images 3. Concrete operational – 7-11 - Logical thinking - able to make decision, logical reasoning 4. Formal operational – 12 – adulthood - thinking: abstract, idealistic, logical (scientific 10 reasoning) 10 20XX presentation title 11 11  20XX presentation title 12 Kohlberg’s Moral development ID, EGO, SUPEREGO ID – impulsive part of personality, instinct – hunger --- need to eat, infants cries when hungry - driven by pleasure, desires, wants, needs repulsed by pain EGO – “self”, conscious part, mediates between id and superego, makes decision SUPEREGO – judgmental, morally correct part of personality, strict Examples: food on the table ID : I'm hungry and need to eat the food SUPEREGO : I'm not going to eat the food – morally wrong to eat someone else’s food EGO; I am hungry but my food will be ready sooner or later, I can wait. Stages 12 Preconventional Morality (3-7 yrs. 0ld) 1 Punishment and obedience 2 Stage of ego Conventional Morality (8-12 y/o) 3 Good boy/Good girl stage 4 Stage of law and order Post conventional Morality : 13 y/o - adulthood 5 Stage of social contract 6 Stage of Universal Principles 12  20XX presentation title 13 Preconventional: -reward and punishment Conventional: -external ethics: school, peer Post conventional: -Personal ethics 13 20XX presentation title 14 14  20XX presentation title 15 Stages 1 Intuitive-Projective Faith (Early childhood) -Intuitive images of good (pleasant, angel) and evil (ugly, scary) - Fantasy and reality = same 2 Mythical-Literal Faith (Middle/Late childhood) - logical concrete thoughts - “God is like a parent figure.” 3 Synthetic-conventional Faith (early adolescent) - more abstract thoughts - conformity to religious belief of others 4 Individuative/Reflective Faith (late adolescent- early adulthood) - full responsibility for their own religious beliefs 5 Conjunctive Faith (Middle adulthood) - open to paradox and opposing viewpoints 6 Universalizing Faith (Middle to late adulthood) - achieve sense of oneness with all being 15  Infancy EDWIN DEL ROSARIO, CCRN, ACNP, AGNP 16 DEVELOPMENTAL MILESTONES LESSON 2 17  INFANT Follows across midline at Social smile at 2 months 3 months First tooth erupts at 6 months Respiratory rate slows Heart rate slows down to 100-120 per minute down to at the end of 1st year 20-30 breaths/min by end of 1 year Liver remains immature Pincer grasp at 10 months Abdomen protuberant Grows in height by 50% (from 20 to 30 inches) Legs may appear short and bowed 20XX presentation title 18 General concepts of a normal infant Pincer grasp: important milestone re: fine motor development - indicates hand dexterity using small muscle groups 18  ANTHROPOMETRICS Body Weight Length Head Proportion 1st 6 mos.: 2 increase by Brain reaches Chest < head lbs./mo. 50% during 2/3 adult size by 2 cm doubles: 4-6 the first year at the end of protuberant mos. 1st year abdomen 2nd 6 mos.: 1 lb./mo. triples : 12 mos. 20XX presentation title 19 Physical growth Weight - double their weight by 4-6 month, triples by 1 year - weight gain - first 6 months – 2 lbs/month - 2nd 6 months - 1lb/month - 1 year old - male: 10 kg (22 lbs) - female: 9.5 kg (21 lb) Length - increase in length during the first year by 50% (20 to 30 inches = 50 cm to 75 cm) Head circumference - end of first year: the brain already reaches 2/3 of its adult size - head circumference increases rapidly = reflects rapid brain growth Body proportion - chest circumference is generally 2 cm less than head circumference - abdomen remains protuberant until they start walking (abdominal 19 muscles are not developed yet) 19  PHYSIOLOGIC CHANGES INFANCY Cardiovascular Hematologic Respiratory GIT HR slows down Physiologic RR slows down amylase to 100-120 anemia @ 2-3 to 20-30/min. deficiency until BP 100/60 mos. Risk for 3rd mo. respiratory lipase deficiency infection until end of 1st year efficiently digest CHON 20XX presentation title 20 Cardiovascular - HR slows down to 100-120 by end of first year - slightly elevated BP from 80/40 to 100/60 Hematologic - prone to develop physiologic anemia at 2-3 mos. - RBC life is 120 days – disintegrate, high Iron demand, iron store from mother lasts for 6-9 months = BREASTFEEDING – low risk to develop anemia due maternal iron stores = bottle feeding – high risk for iron deficiency anemia @ 2-3 mos. - cow milk is iron fortified Respiratory - slows down to 20-30 /minute - immature respiratory system ; prone to develop respiratory infection GIT - lactose and fat intolerant = colic 20  - deficient in amount of amylase until 3 rd month = needed for CHO digestion - can efficiently digest CHON - deficient lipase (fat digestion) until end of first year - immature liver : inadequate conjugation of drugs - extrusion reflex appears until 3-4 months : protection to prevent early infant feeding - independently drink from a cup @ 8-10 months 20  PHYSIOLOGIC CHANGES INFANCY GUT Immunity Thermoregulation Kidneys remain Functional Able to adjust to immature immune system cold by 6 mos. diluted urine by 2 mos. Subcutaneous Able to produce tissue increases, IgG and IgM by 1 Brown fats year decreases 20XX presentation title 21 GUT - kidneys remains immature: Immunity - infants immune system become functional by 2 months of age - able to produce both IgG and IgM by 1 year (helps to fight respiratory pathogen) Thermoregulation - able to adjust to cold by age 6 months - can shiver in response to cold - develop adequate adipose tissue for insulation - brown fats (protect NB from cold) decreases, subcutaneous fats increases 21  6-12 mos. 20XX presentation title 22 TEETH/DENTITION - first baby tooth usually erupts at age 6 month, followed by new tooth monthly until 20 deciduous teeth erupted by age 2-3 yrs. - NATAL TEETH : born with tooth, usually the lower central incisor - remove if loose, if not keep them until permanent teeth erupts 22  Developmental milestones 20XX presentation title 23 Developmental milestones - are behaviors or physical skills seen in infants and children as they grow and develop. - Rolling over, crawling, walking, and talking are all considered milestones. - The milestones are different for each age range. - There is a normal range in which a child may reach each milestone. For example, walking may begin as early as 8 months in some children. Others walk as late as 18 months and it is still considered normal. Below is a general list of some of the things you might see children doing at different ages. These are NOT precise guidelines. There are many different normal paces and patterns of development. Infant -- birth to 1 year Able to drink from a cup Able to sit alone, without support Babbles Displays social smile 23  Gets the first tooth Plays peek-a-boo Pulls self to a standing position Rolls over by self Says mama and dada, using terms appropriately Understands "NO" and will stop activity in response Walks while holding on to furniture or other support 23  GROSS MOTOR DEVELOPMENT MONTHS GROSS MOTOR DEVELOPMENT 0-1 Largely reflex Actions 2 Holds heads up when prone (head control) 3 Holds heads and chest up when prone 4 Turns back to front no loner has head lag; bears partial weight on feet 5 Should turn readily front to back and back to front 6 Beginning to show ability to sit; first tooth (central incisor) erupt 7 Reaches out to be picked up; Sits alone but only when hands are held forward for balance 8 Sits securely without support 9 Creeps or crawl (abdomen off floor); sit steadily that they can lean forward & reg their balance 10 Pulls self to standing 11 Cruises (walks with support) 12 Stands alone, some infants take first step 20XX presentation title 24 Month Motor Development 0-1 Largely reflex Actions 2 Holds heads up when prone 3 Holds heads and chest up when prone 4 Turns back to front no loner has head lag; bears partial weight on feet 5 Should turn readily front to back and back to front 6 Beginning to show ability to sit; first tooth (central incisor) erupt 7 Reaches out to be picked up; Sits alone but only when hands are held forward for balance 8 Sits securely without support 9 Creeps or crawl (abdomen off floor); sit steadily that they can lean forward & regain 24  their balance. 10 Pulls self to standing 11 Cruises (walks with support) 12 Stands alone, some infants take first step 24  MOTOR DEVELOPMENT 20XX presentation title 25 Normal Age range (still considered normal) - any deviations/delayed: concern for further investigation Different children pass through #3 --- the predictable stages at different rates. 25  FINE MOTOR DEVELOPMENT MONTH FINE MOTOR DEVELOPMENT 0-1 Keeps hand fisted; able to follow object to midline with eyes 2 Hold object for few mins before dropping it 3 Follows object past midlines with eyes; reach for attractive objects in front of them 4 Bring their hands together and pull at their clothes. THUMB OPPOSITION 5 can reach & pick up toys without being offered & often play with their toes as objects 6 Can hold objects in both hands. PALMAR GRASP& TONIC NECK REFLEXES – completely faded 7 Transfer objects hand to hand 8 Advanced eye-hand coordination 9 10 Uses pincer grasp (thumb and finger) to pick up small objects 11 20XX presentation title 26 12 Holds cup and spoon well; helps to dress (pushes arm into sleeves) Month Fine Motor Development 0-1 Keeps hand fisted; able to follow object to midline with eyes 2 Hold object for few mins before dropping it 3 Follows object past midlines with eyes; reach for attractive objects in front of them 4 Bring their hands together and pull at their clothes. THUMB OPPOSITION 5 can reach & pick up toys without being offered & 26 often play with their toes as objects 6 Can hold objects in both hands. PALMAR GRASP& TONIC NECK REFLEXES –completely faded 7 Transfer objects hand to hand 8 Advanced eye-hand coordination 9 10 Uses pincer grasp (thumb and index finger) to pick up small objects : important fine motor skills - hand- eye coordination - coordination of brain and muscle 11 12 Holds cup and spoon well; helps to dress (pushes arm into sleeves) 26  Socialization and Language MONTH SOCIALIZATION AND LANGUANGE 0-1 2 Makes cooing sounds; differentiates cry, social smile 3 Laughs out loud 4 5 Say simple vowel sounds (”goo-goo”; ”gah-gah” 6 May say vowel sounds (oh-oh) 7 Shows beginning fear of strangers 8 Fears of strangers peaks 9 Says first word da da 10 Infant masters another word such as “ bye-bye” or “no” 11 12 Says 2 words plus ma ma and da da; used this words with meaning 20XX presentation title 27 Month Socialization and Language 0-1 2 Makes cooing sounds; differentiates cry 3 Laughs out loud 4 5 Say simple vowel sounds (”goo-goo”; ”gah-gah” 6 May say vowel sounds (oh-oh) 7 Shows beginning fear of strangers 8 Fears of strangers peaks 9 Says first word da da 10 Infant masters another word such as “ bye-bye” or “no” 11 12 Says 2 words plus ma ma and da da; used this words with meaning Language development 27  1 month – begin small cooing sounds 2 months – can differentiate their cry, caregiver be able to distinguish cry that means hungry or wet 3 months – squeals with pleasure or laugh aloud, response to nodding, smiling face, friendly tone of voice 4 months – infants are talkative, when spoken to, starts cooing, babbling, gurgling, laugh aloud 5 months – say simple bowels sounds (goo-goo, gah-gah) 6 months – learn the art of imitating, imitates parent cough, imitate vowel sounds (0h-oh, ah-ah, oo-oo) 9 months – speaks first words (da-da, ba-ba) 10 months – master another word (bye-bye, no) 12 months – say additional two words, use words with meaning Development of Senses Vision 1 months – able to regard an object in the midline of their vision when brought close to vision about 18 inches - regards human face follows object at distance, not across the midline 2 months – follows moving objects with eyes and focus = achieved binocular vision (ability to fuse 2 objects into 1) - “eye to eye” contact with caregiver 3 months’ - follows objects across midline - hold hand in front of their face ( hand regard) 4 months - recognize familiar object, follows caregiver movements 7 months - pat own image in the mirror - transfer toys from hand to hand 10 months - looks under towel or around corner for a concealed object (Object permanence) – awareness that an object out of sight still exist Hearing NB – quiet momentarily at distinctive sounds (bell, squeaky rubber toy) 1 month = hearing test recommended 1 month 27  2 months – stops an activity at a sound of spoken words 3 months – turn head to locate a sound 4 month – hears distinctive sounds, turn and look into direction of sound 5 months – localizes sounds downward and to the sides 6 months – locate sound made above them 10 months – recognize name and when spoken to, listen intently 12 months – locate sounds in any directions, vocabulary of 4 words - enjoys soft musical sounds Touch - need to be touched, skin-skin contact - diaper needs to be dry rather than wet Taste - turning away or spitting from taste they do not enjoy - introduce solid food at 6 months Smell - highly developed within 1-2 hrs, after birth - sneezing when smells irritate them Emotional Development Socialization 1 month – differentiate between faces and objects, appears calm when caregiver face is present 2 months – social smile 3 months – readily smiling at a sight of caregiver face 4 months – 5 months – shows displeasure when object is taken away from them 6 months – begins to draw back from unfamiliar faces 7 months – obvious fear of stranger 8 months – stranger anxiety peaks (eight-month anxiety) 9 months – aware of the changes in the tone of voice 12 months - overcome fear of stranger - play interactive nursery rhythm, dance with others 27  Time Reflexes Fade MONTH TIME REFLEXES FADE 01-1 2 Grasp reflexes fading 3 Landau reflex is strong 4 Stepping, tonic neck extrusion reflexes are fading 5 Tonic neck reflex fading 6 Moro and Tonic neck reflex have completely faded 7 8 9 10 11 12 Landau reflexes fades 20XX presentation title 28 Time Reflexes Fade Month Time Reflexes Fade 0-1 2 Grasp reflexes fading 3 Landau reflex is strong 4 Stepping, tonic neck extrusion reflexes are fading 5 Tonic neck reflex fading 6 Moro and Tonic neck reflex have completely faded 7 8 9 10 11 12 Landau reflexes fades 28 28  PLAY MONTH PLAY 0-1 Enjoy watching face of primary caregiver; needs play time in prone position 2 Enjoys bright colored mobiles 3 Spends time looking at hands (hand regard); “tummy time” important during the day 4 Needs space to practice turning 5 Handles rattle well 6 Enjoys bathtub toys, rubber ring for teething 7 Likes objects that are good size for transferring 8 Enjoys manipulation, rattles, and toys of different textures 9 Needs safe space for creeping 10 Plays games like patty-cake and peek-a-boo 11 Cruising can be main activity 12 Likes toys that fit inside each other (pots and pans); nursery rhymes, will like pull toys as 20XX soon as walking presentation title 29 Play Month Play 0-1 Enjoy watching face of primary caregiver; needs play time in prone position 2 Enjoys bright colored mobiles 3 Spends time looking at hands (hand regard); “tummy time” important during the day 4 Needs space to practice turning 5 Handles rattle well 6 Enjoys bathub toys, rubber ring for teething 7 Likes objects that are good size for transferring 8 Enjoys manipulation, rattles, and toys of different textures 29  9 Needs safe space for creeping 10 Plays games like patty- cake and peek-a-boo 11 Cruising can be main activity 12 Likes toys that fit inside each other (pots and pans); nursery rhymes, will like pull toys as soon as walking 1 month ` - fix eyes on objects, interested in watching mobiles over crib - mobiles are best (balck, white, brightly colored, musical mobiles) - watching caregiver face (face becomes favorite toy) 2 months - hold light, small rattles then drop them - watching faces around them 3 months - handle small blocks or rattles 4 months’ - needs a playpen to exercise skill of rolling over 5 months - ready for variety of objects to handle - small enough to lift but big enough not possibly swallow them 6 months - can sit steadily, ready for bathtub toys - enjoys teething toy to chew 7 months - transfer toys 8 months - sensitive in difference in textures, enjoys toys with different textures ( velvet, rubber, fuzzy smooth) 9 months - enjoys toys that go inside each other - creep/crawl 10 months - “peek-a-boo” - actively participate in play 11 months - cruise/walk 12 months - putting things and taking thing out of container 29 - interested in pull toys as they walk - recite nursery rhythms 29  MONTH MOTOR FINE MOTOR SOCIALIZATION TIME REFLEX PLAY LANGUANGE FADES 0-1 Large reflex action Keeps hand fisted, Enjoys watching able to follow faces of caregiver object to midline Needs playtime in with eyes prone position 2 Holds head up Social smile Makes cooing Grasp reflex fading Enjoys bright when prone sound, differentiates colored mobile cry 3 Hold head and Follows object past Laughs out loud Landau reflex is Spends time looking chest up when midlin e with eyes strong at hand (hand prone regard) “tummy time” 4 Turns back to front Stepping, tonic neck Needs space to No head lag and extrusion reflex practice turning fadin g 20XX presentation title 30 MOTOR DEVELOPMENT - Progresses thru systemic motor development during 1 st year =reflects cephalocaudal principle A. gross motor – involves large body movement B. fine motor – assess prehensile ability, ability to coordinate hand movements Gross motor Ventral suspension – refers to infant appearance when held in midair on horizontal plane, supported by a hand under the abdomen - 1 month – lift their head momentarily and drop it again - 2 months – hold head in the same plane as the rest of the body = reflect muscle control - 3 months – lifts and maintain head well above the plane of the rest of the body in ventral suspension Landau reflex – develops at 3 months until 6 months of life - when held in ventral position, the head, legs and spine extend - unable to perform: cerebral palsy, neuromuscular 30 defect parachute reflex – develops at 6-9 months - infant suddenly lowered, arm extends as if to protect themselves from falling Prone position - lying on their stomach - 1 month – lift head and turn easily to the sides - keep knee tucked under abdomen - 2 months – raise head and maintain position, cannot raise chest - 3 months –lift the head and shoulder and looks around when prone - turn from a prone to a side-lying position 4 months – lift chest off the bed and look around actively, turn head side to side - “neck righting reflex” – extension of lifting the chest, lose their balance and roll sideways when lifting the head 5 months – turn from back to front - able to rest weight on their forearm when prone 6 months – raise their chest and upper part of their abdomen off the table 9 months – creep from the prone position Sitting newborn – extreme head lag 2 months – hold head steadily when sitting up 4 months – no head lag when pulled to a sitting position 5 months – straighten their back when held in sitting position 7 months – sit alone only when the hands are held forward for balance 8 months – sit without support 9 months – sit steadily that they can lean forward and regain balance Standing NB to 1 month – stepping reflex present 3 months – try to support part of the weight on their feet 4 months – able to support weight on legs, steeping reflex faded 5 months – tonic neck and Moro reflexes fading 6 months – support weight when standing 30  7 months – bounces with enjoyment 9 months – can stand up 10 months – pull themselves up to standing position 11 months – can cruise around crib 12 months – can stand alone and walk - child has until 22 months of age to walk and considered still normal FINE MOTOR 1 month – strong gasp reflex, hold object tightly, difficult to extend their fingers 2 months – grasp reflex faded, hold object for few minute and drop it. Hand held open 3 months – reach for attractive object in front of them, unpracticed grasping, easily miss object 4 months – bring hands together and pull at their clothes - :thumb apposition” – ability to bring the thumb and finger together 5 months – accepts object that are handed to them by grasping 6 months – hold object in both hands, drop one toy when a 2nd one is offered - moro, palmar grasp and tonic neck neck completely disappeared - moro reflex persist beyond 6 months – suspect neurologic damage 7 month – transfer toy from ne hand to another 8 months – random reaching objects 10 months – ability to bring thumb and first finger together in a pincer grasp 12 months – hold a crayon well to draw as semi straight line - hold cup and spoon to feed themselves 30 MONTH MOTOR FINE MOTOR SOCIALIZATION TIME REFLEX PLAY LANGUANGE FADES 5 Turn readily from Tonic neck fading Handles rattle well front to back , then back to front 6 Begin to show Use palmar grasp May say vowel Moro and tonic Enjoys bath tub ability to sit sounds (oh-oh) neck have faded toys, rubber ring First tooth (central for teething incisor) erupts 7 Reaches out to be Transfer object Show beginning Likes objects that picked up. hand to hand fear of stranger are good size for transferring 8 Sits without Fear of stranger Enjoys rattles, support manipulations, toys of different texture 20XX presentation title 31 MOTOR DEVELOPMENT - Progresses thru systemic motor development during 1 st year =reflects cephalocaudal principle A. gross motor – involves large body movement B. fine motor – assess prehensile ability, ability to coordinate hand movements Gross motor Ventral suspension – refers to infant appearance when held in midair on horizontal plane, supported by a hand under the abdomen - 1 month – lift their head momentarily and drop it again - 2 months – hold head in the same plane as the rest of the body = reflect muscle control - 3 months – lifts and maintain head well above the plane of the rest of the body in ventral suspension Landau reflex – develops at 3 months until 6 months of life - when held in ventral position, the head, legs and spine extend - unable to perform: cerebral palsy, neuromuscular 31 defect parachute reflex – develops at 6-9 months - infant suddenly lowered, arm extends as if to protect themselves from falling Prone position - lying on their stomach - 1 month – lift head and turneasily to the sides - keep knee tucked under abdomen - 2 months – raise head and maintain position, cannot raise chest - 3 months –lift the head and shoulder and looks around when prone - turn from a prone to a side-lying position 4 months – lift chest off the bed and look around actively, turn head side to side - “neck righting reflex” – extension of lifting the chest, lose their balance and roll sideways when lifting the head 5 months – turn from back to front - able to rest weight on their forearm when prone 6 months – raise their chest and upper part of their abdomen off the table 9 months – creep from the prone position Sitting newborn – extreme head lag 2 months – hold head steadily when sitting up 4 months – no head lag when pulled to a sitting position 5 months – straighten their back when held in sitting position 7 months – sit alone only when the hands are held forward for balance 8 months – sit without support 9 months – sit steadily that they can lean forward and regain balance Standing NB to 1 month – stepping reflex present 3 months – try to support part of the weight on their feet 4 months – able to support weight on legs, steeping reflex faded 5 months – tonic neck and moro reflexes fading 6 months – support weight when standing 31  7 months – bounces with enjoyment 9 months – can stand up 10 months – pull themselves up to standing position 11 months – can cruise around crib 12 months – can stand alone and walk - child has until 22 months of age to walk and considered still normal FINE MOTOR 1 month – strong gasp reflex, hold object tightly, difficult to extend their fingers 2 months – grasp reflex faded, hold object for few minute and drop it. Hand held open 3 months – reach for attractive object in front of them, unpracticed grasping, easily miss object 4 months – bring hands together and pull at their clothes - :thumb apposition” – ability to bring the thumb and finger together 5 months – accepts object that are handed to them by grasping 6 months – hold object in both hands, drop one toy when a 2nd one is offered - moro, palmar grasp and tonic neck neck completely disappeared - moro reflex persist beyond 6 months – suspect neurologic damage 7 month – transfer toy from ne hand to another 8 months – random reaching objects 10 months – ability to bring thumb and first finger together in a pincer grasp 12 months – hold a crayon well to draw as semi straight line - hold cup and spoon to feed themselves 31  MONTH MOTOR FINE MOTOR SOCIALIZATION TIME REFLEX PLAY LANGUANGE FADES 9 Creeps Say first word Needs safe space crawl for creeping 10 Pulls self to Use pincer grasp Plays games standing Peek-a-boo 11 Cruises (walk with Cruising can be support) main activity 12 Stand alone, some Hold cup and Say four words Landau reflex Likes toys that fits takes first step spoon fades inside each other Helps to dress (pots and (pushes arm to pans)nursery sleeves) rhythms, likes pull toys as soon as walking 20XX presentation title 32 MOTOR DEVELOPMENT - Progresses thru systemic motor development during 1 st year =reflects cephalocaudal principle A. gross motor – involves large body movement B. fine motor – assess prehensile ability, ability to coordinate hand movements Gross motor Ventral suspension – refers to infant appearance when held in midair on horizontal plane, supported by a hand under the abdomen - 1 month – lift their head momentarily and drop it again - 2 months – hold head in the same plane as the rest of the body = reflect muscle control - 3 months – lifts and maintain head well above the plane of the rest of the body in ventral suspension Landau reflex – develops at 3 months until 6 months of life - when held in ventral position, the head, legs and spine extend - unable to perform: cerebral palsy, neuromuscular 32 defect parachute reflex – develops at 6-9 months - infant suddenly lowered, arm extends as if to protect themselves from falling Prone position - lying on their stomach - 1 month – lift head and turneasily to the sides - keep knee tucked under abdomen - 2 months – raise head and maintain position, cannot raise chest - 3 months –lift the head and shoulder and looks around when prone - turn from a prone to a side-lying position 4 months – lift chest off the bed and look around actively, turn head side to side - “neck righting reflex” – extension of lifting the chest, lose their balance and roll sideways when lifting the head 5 months – turn from back to front - able to rest weight on their forearm when prone 6 months – raise their chest and upper part of their abdomen off the table 9 months – creep from the prone position Sitting newborn – extreme head lag 2 months – hold head steadily when sitting up 4 months – no head lag when pulled to a sitting position 5 months – straighten their back when held in sitting position 7 months – sit alone only when the hands are held forward for balance 8 months – sit without support 9 months – sit steadily that they can lean forward and regain balance Standing NB to 1 month – stepping reflex present 3 months – try to support part of the weight on their feet 4 months – able to support weight on legs, steeping reflex faded 5 months – tonic neck and moro reflexes fading 6 months – support weight when standing 32  7 months – bounces with enjoyment 9 months – can stand up 10 months – pull themselves up to standing position 11 months – can cruise around crib 12 months – can stand alone and walk - child has until 22 months of age to walk and considered still normal FINE MOTOR 1 month – strong gasp reflex, hold object tightly, difficult to extend their fingers 2 months – grasp reflex faded, hold object for few minute and drop it. Hand held open 3 months – reach for attractive object in front of them, unpracticed grasping, easily miss object 4 months – bring hands together and pull at their clothes - :thumb apposition” – ability to bring the thumb and finger together 5 months – accepts object that are handed to them by grasping 6 months – hold object in both hands, drop one toy when a 2nd one is offered - moro, palmar grasp and tonic neck neck completely disappeared - moro reflex persist beyond 6 months – suspect neurologic damage 7 month – transfer toy from ne hand to another 8 months – random reaching objects 10 months – ability to bring thumb and first finger together in a pincer grasp 12 months – hold a crayon well to draw as semi straight line - hold cup and spoon to feed themselves 32  DEVELOMENTAL MILESTONE: INFANCY Psychoanalytic Psychosocial Cognitive Moral (Freud) (Erickson) (Piaget) (Kohlberg) Preconventional Trust vs, Sensorimotor Oral phase (punishment mistrust stage and obedience) 20XX presentation title 33 Oral phase - gratification thru the mouth - grasp object and put directly to the mouth Trust vs. mistrust - developmental task of an infant is to develop sense of trust - develop trust from caregiver - trust arises form a sense of confidence and consistency - gentle rhythm of care gives infant as sense of being able to predict what is going to happen and give life consistency - caregiver task: anticipate all infant need Cognitive - instinctual and reflexive - aims to acquire basic needs – achieve satisfaction Moral - no sense of morality yet - “self-centered” – aims to fulfill owns needs 33 - punishment and obedience : REWARD AND PUNISHMENT 33  PROMOTING SAFETY: INFANCY Round, cylindrical objects Aspiration Grasp and suck automatically No peanut, carrots, hotdogs, grapes Fall able to turn @ 2 mos. Car safety backward-facing seat in the back seat Needs supervision @ all time Safety with siblings With preschool – sibling rivalry Bathing/swimming Never leave unattended Childproofing Lock all cabinet 20XX presentation title 34 Promoting infant safety Unintentional injuries – leading cause of death in children 1 month to 2 years - important to establish sound caregiver-child relationship, guard infant safety 1. aspiration precaution - round, cylindrical objects are more dangerous than square, flexible objects (carrot, hotdog, grapes) - NB grasp and sucks objects automatically – nothing within infant reach (reflexive action) - test : objects fits inside toilet paper roll = dangerous - under 5 year old : no peanut, popcorn 2. Fall prevention - prepared for caregiver to turn over at age 2 months – not leave unattended - 2 months – maximum length of time infant can be safely sleep in bassinet 3. Car safety - placed in backward-facing seats in the back seat, inflating front seat 34 airbag can suffocate infant - until child reaches the highest height and weight by the car seat manufacturer 4. Safety with sibling - more interactive at age 3 months : do not leave unattended - with preschooler – sibling rivalry – may harm an infant if left alone 5. bathing/swimming - never leave unattended in tub - able to support back – can use adult bath tub 6. childproofing - begin teething @ 5-6 months – check for possible sources of lead paint = avoid lead poisoning - play on the floor – cover electrical sockets, move furniture to cover them, use protective cap for outlets - use safety gates – top/bottom of stairs - lock all cabinets 34  NUTRITION Complementary Birth to 6 mos. 6 mos. To 1 yr. feeding 6 mos. : ideal to Breastmilk Continue breast introduce solid exclusively milk foods Chewing begins 7-9 Cow’s milk not Needs supplement months, extrusion recommended Iron reflex fades 4-6 under 1 yr. old mos. 20XX presentation title 35 NUTRITION Birth to 6 months - provide human milk exclusively , breastfeeding - must have Vit D supplement starting @ age 2 weeks (bottle fed do not need ViT D supplement) - ideal form of nutrition, protective against disease, supports infant growth and development - cow milk not recommended prior to 1 year of age - difficult to digest, leading to intestinal irritation --- slight GI bleeding --- anemia - should be IRON fortified 6 months to 1 year - continue breast feeding - exclusively human milk fed – needs fluoride and iron at 6 months = iron stores from mother lasts for 6 months only 6 month - ideal to introduce solid food - chewing movement begins 7-9 months, extrusion reflex fades 35 Complementary food Signs infant is ready for complementary foods (CSOGE) 1. being to control the head and neck – prevent aspiration 2. sitting up alone or with support – prevent aspiration 3. bringing object to mouth 4. trying to grasp small object 5. swallowing food rather pushing 35 Health needs and Health Promotion Activities LESSON 3 36  HEALTH PROMOTIONS Feeding Bathing Diaper care Dental care Sleep Age and Change 0-3 mos. : 14 No need a developmentally frequently Toothbrushing hrs. sleep, 2-3 appropriate bath everyday every 2-4 hrs. hrs. at a time initially choking hazards: Rubbing soft Seborrhea hotdog, candy, washcloth over dermatitis Diaper rash nuts, seeds, gums before teeth 3-12 mos.: 13 (cradle cap) carrot, grapes erupts hrs. sleep Introduce one Soft toothbrush 2x/d : once tooth food at a time erupts 20XX presentation title 37 Providing safe feeding - age appropriate and developmentally appropriate to prevent choking - choking hazards : hotdog, candy, nuts, seeds, carrots, grapes, popcorn, chunks - introduce 1 food at a time – assess for food allergy Bathing - except in hot weather ; no need a bath everyday - no need to bath head and scalp frequently = prevent seborrhea – extreme dryness - seborrhea develops = use mineral oil and shampooing the scalp, use fine comb or toothbrush to remove crust Diaper care - change diaper frequently, every 2-4 hrs. - develops rash = air drying or sleeping without diaper - use petroleum jelly – barrier for urine and stool - no talc powder – associated with ovarian cancer and lung cancer (asbestos) Dental care 37  - fluoridated water – effective way to promote healthy toot formation - toothbrushing – can start even before teeth erupts by rubbing soft washcloth over gum pads - once tooth erupts : brush with soft toothbrush twice a day Dressing Sleep - birth to 3 months : average of 14 hrs. sleep, 2-3 hrs at a time initially - 3-12 month : need 13 hrs 37  EMOTIONAL & SOCIAL NEEDS MONTH EMOTIONAL AND SOCIAL NEEDS 1 can differentiate between faces and other objects by studying a face or a picture of a face longer than other objects 4 when a person who has been playing with and entertaining the infant leaves, an infant is likely to cry to show he or she enjoyed the interaction, recognize the primary caregiver 5 May show displeasure when object is taken away 6 increasingly aware of the difference of people who regularly care for them and strangers, begin to draw back from unfamiliar people 7 Fear of stranger 8 fear of strangers at its height (eight-month anxiety) 9 aware of changes in tone of voice, cry when scolded not because they understand what is being said but because they sense their parents displeasure 12 fear of strangers overcome 20XX presentation title 38 1 month old: can differentiate between faces and other objects by studying a face or a picture of a face longer than other objects 4 months: when a person who has been playing with and entertaining the infant leaves, an infant is likely to cry to show he or she enjoyed the interaction, recognize the primary caregiver 5 months : May show displeasure when object is taken away 6 months: increasingly aware of the difference of people who regularly care for them and strangers, begin to draw back from unfamiliar people 7 months : Fear of stranger 8 months: 38  fear of strangers at its height (eight- month anxiety) 9 months: aware of changes in tone of voice, cry when scolded not because they understand what is being said but because they sense their parents displeasure 12 months fear of strangers overcome, alert and responsive when approached 38 Immunization LESSON 4 39  20XX presentation title 40 Immunization means protection. - The most effective and safe way to protect children from contagious diseases is by vaccination. - Vaccines are considered a breakthrough in preventive medicine. Vaccines protect your child’s health by preventing them from contracting severe contagious diseases. 40  20XX presentation title 41 VACCINE REQUIREMENTS - However, each state has their own laws about which vaccines are required for children to attend public or private school, daycare, or college. Here are the essentials to know about each of these vaccines. HepB protects against hepatitis (infection of the liver). HepB is given in three shots. The first shot is given at the time of birth. Most states require HepB vaccination for a child to enter school. DTaP protects against diphtheria, tetanus, and pertussis (whooping cough). It requires five doses during infancy and childhood. DTaP boosters are then given during adolescence and adulthood. MMR protects against measles, mumps, and rubella (German measles). MMR is given in two doses. The first dose is recommended for infants between 9 and 12 months. The second dose is usually given between ages 4 and 6 years. However, it can be given as soon as 28 41  days after the first dose. RV protects against rotavirus, a major cause of diarrhea. RV is given in two or three doses, depending on the vaccine used. Hib protects against Haemophilus influenzae type b. This infection used to be a leading cause of bacterial meningitis, Hib vaccination is given in three or four doses. PCV protects against pneumococcal disease, which includes pneumonia. PCV is given in a series of four doses. Influenza (flu) protects against the flu. This is a seasonal vaccine that is given yearly. Flu shots can be given to your child each year, starting at age 6 months. Flu season can run from September through May. Varicella protects against chickenpox. Varicella is recommended for all healthy children. It’s given in two doses. HepA protects against hepatitis. This is given as two doses between 1 and 2 years of age. 41  GENERAL PRINCIPLE FOR CHILD IMMUNIZATION 20XX presentation title 42 GENERAL PRINCIPLE FOR CHILD IMMUNIZATION 1. It is safe and immunologically effective to administer all EPI vaccine on the same day at different sites of the body. 2. Measles vaccine should be given as soon as the child is 9 months old, regardless of whether other vaccines will be given on that day. 3. The vaccination schedule should not be restarted from the beginning even if the interval between doses exceeded the recommended interval by months or years. 4. Moderate fever, malnutrition, and respiratory infection, cough, diarrhea and vomiting. are not contraindications to vaccination. Generally, one should immunize unless the child is so sick that he needs. to be hospitalized. Then the hospital needs to decide on when to immunize the child. 42  CONTRAINDICATION ON IMMUNIZATION had convulsions or shock within 3 days of DPT the previous dose child with clinical AIDS BCG 20XX presentation title 43 DPT2 or DPT3 to a child who has had convulsions or shock within 3 days of the previous dose BCG vaccine to a child with clinical AIDS Repeat BCG vaccination if the child does not develop a scar after the 1st injection. 43  Common Health Problems of Infant LESSON 5 Most Common Health Issues for Infants Whether you're a first-time parent or not, taking care of your precious, helpless infant is your most important job. Babies are usually resilient, but it's essential for you to know the warning signs of common health issues for infants. Knowing what symptoms to look for and what to do when your baby shows signs of an illness can help you love and care for your baby. Infants do pick up illnesses from time to time, and with proper care, it's usually nothing to worry about. are sharing the warning signs and what to do in the case of some common childhood illnesses below. EAR INFECTIONS Ear infections and pain are common in children. Your little one might pull or rub at their ears, and they might be fussier or more tearful than usual. They might also have trouble sleeping or lose their appetite. Bring any child under the age of 6 months to our clinic when they show signs of an ear infection. If you have an older baby, they should see one of our skilled doctors if they have a fever and symptoms of an ear infection. 44 COLDS AND SORE THROATS Babies can pick up colds and upper respiratory infections and suffer from sneezing, congestion, coughs, and sore throats. Bring your baby to our office if they have: A fever of 100.4F or more Trouble breathing A thick green discharge for several days If your baby is younger than 3 months, you should bring them to our office at the first sign of a cold. COLIC Many babies experience colic, a type of gastroesophageal reflux. It's uncomfortable and typically causes excessive crying and makes it difficult for you to soothe them or get your baby to sleep. If your baby continually cries, make an appointment with our team. can examine your baby and might recommend a different feeding schedule, a different formula, or even medication to soothe their symptoms. DIGESTIVE PROBLEMS Babies' bowel movements are typically irregular for their first year of life, but they can experience constipation and diarrhea. Most of the time, these issues are temporary and subside quickly. If your baby suffers from chronic constipation or diarrhea, especially if they have a fever, you should bring them to our office to find the cause and get the treatment they need. SKIN RASHES AND INFECTIONS It’s not unusual for children to get skin rashes and infections like ringworm. When you see a rash on your little one, apply a small amount of an antihistamine. If that doesn't clear the infection, try an antifungal cream. If the skin problem still doesn’t go away, schedule an appointment with a member of our medical team. ALLERGIES Allergies are very common in children. If your child shows signs of an allergy like skin rashes, hives, itchy eyes, or swelling, give us a call to schedule allergy testing. Knowing what causes your little one's allergies will help you to prevent future allergic reactions and manage their health. 44  Health concerns Thumb Use of Head Teething sucking pacifier banging Signs Reassure parent: sore, tend er gum s prior Can cause tooth to tooth eruption infant satisfies Sign of autism resistant to chewin g sucking pleasure malocclusion Fever, vomiting, diarrhea, earache, fussiness Intervention Ignore Teething rings placed in refrigerator 20XX presentation title 45 A baby needs to be healthy so she can learn and grow. Babies should have regular checkups, and keep their immunizations up to date. Sleep is important for the baby too, so help them get plenty of sleep. The baby's brain cells make important connections during sleep, which help with learning, movement Parental concern and problems 1. Teething -eruption of the deciduous (primary) teeth -age of tooth eruption shows considerable variation among children -physiologic process; some discomfort is common as the crown of the tooth breaks through the periodontal membrane. -gums are sore and tender prior to tooth eruption - resistant to chewing - signs L fever, seizure, vomiting, diarrhea, earache, fussiness - use teething rings placed in refrigerator = soothing coolness to the gums 45  - Interventions -cold is soothing -Giving the child a frozen teething ring or an ice cubes wrapped in a washcloth helps - relieve the inflammation. - nonprescription topical anesthetic ointments are available, such as Baby Ora- 2. Thumb sucking - is common, does not deform the jaw - best approach it to be certain that infant has adequate sucking pleasure and then ignore thumb sucking 3. Use of pacifier -infant's chief pleasure and may not be satisfied by breast or bottle-feeding -reaches its peak at age 18 to 20 months and is most prevalent when the child is hungry, sick, or tired -during infancy and early childhood, no need to restrain nonnutritive sucking of the fingers unless the habit extends into the late preschool years -Malocclusion may occur if thumb sucking persists past 4 to 6 years or when the permanent teeth erupt pacifier use in infancy is associated with a higher incidence of malocclusion, 4. Head banging - Rhythmically banging -pad the rails of crib so heads against bars of a they cannot hurt crib for a period of time themselves before falling sleep -reassure that this is a normal - begins during the second normal mechanism for half of the first year of life relief of tension up to preschool period -associated with naptime or bedtime, lasting for 15 minutes (normal) -use it to relax or fall sleep - can be sign of autism - advise ; pad the rails 45  Neonatal Common Health Problems -more common bottle- -add more fluids or carbohydrates/sugar -adding foods with bulk, such as fruits and vegetables -if anal sphincter is tight, dilate 2-3 x daily with gloved little finger Constipation - fed infants, fluid deficit -Oralrehydration Treat the cause Loose stools : 20XX presentation title 46 Health Problem Definition Intervention Constipation -more common bottle- -add more fluids or carbohydrates/sugar -adding foods with bulk, such as fruits and vegetables -if anal sphincter is tight, dilate 2-3 x daily with gloved little finger fed infants, fluid deficit Loose stools : Oral rehydration Treat the cause 46  Neonatal Common Health Problems paroxysmal abdominal pain occurring in infants under 3 months of age -a -face becomes red and flushed, fists clenched, abdomen becomes tense - causes - overfeeding - gas distention - too much carbohydrates tense and unsure mother - due to poorly developed sphincter - Prevention Colic/Spitting -feed by self demand -burp the baby twice during a feeding up - feed in upright position -change milk formula, if needed -reduce sugar content -feed in upright position -position on right side after feeding - burp more frequently 20XX presentation title 47 Colic Spitting up -a paroxysmal abdominal pain occurring in infants under 3 months of age -face becomes red and flushed, fists clenched, abdomen becomes tense Causes: - overfeeding – lactose and fat intolerant - gas distention - too much carbohydrates tense and unsure mother - due to poorly developed sphincter Prevention -feed by self demand -burp the baby twice during a feeding - feed in upright position -change milk formula, if needed -reduce sugar content 47 -feed in upright position -position on right side after feeding - burp more frequently 47 20XX presentation title 48 48  Neonatal Common Health Problems causes may be due to poor hygiene irritation from urine, feces, detergents Prevention expose to air Skin Irritation careful washing starch bath (Miliaria) 20XX presentation title 49 Health Problem Definition Intervention Skin irritation -may be due to poor - expose to air hygiene -irritation from - careful washing and urine, feces or laundry rinsing of skin products - starch bath (for Miliaria or prickly-heat rash) 49  Neonatal Common Health Problems Causes poor hygiene Prevention Seborrheic mineral oil dermatitis shampoo bath in the morning 20XX presentation title 50 Seborrheic dermatitis -involves sebaceous -apply mineral oil or /cradle cap glands Vaseline on the scalp at -due to poor hygiene night - giving shampoo bath in the morning 50  Neonatal Common Health Problems Cluster of pinpoint rashes during hot weather Neck, nose, around the ears Prevention Bathe 2x/d Miliaria Baking soda Reduce amount of clothing 20XX presentation title 51 Miliaria or prickly heat -clusters of pinpoint, -Bathe infant twice a day rash reddened papules with during hot weather occasional vesicles and -small amount of baking pustules surrounded by soda to be added to the erythema usually on the bath water neck to around the ears -reduce amount of and unto the face down clothing onto the trunk -lower room temperature -occurs most often in warm weather or when babies are overdressed or sleep in overheated rooms 51 51  Neonatal Common Health Problems Definition putting an infant to bed with a bottle Baby- Health concerns aspiration bottle tooth decay – CHO content (milk) Ear infection Syndrome Intervention Never put to bed with a bottle Use nipple with smaller hole Use diluted milk formula 20XX presentation title 52 Baby-Bottle Syndrome -putting an infant to bed with a bottle can result in aspiration and decay of all the upper teeth and the lower posterior teeth -liquid from the propped bottle continuously soaks the upper front teeth and lower back teeth -most serious when the bottle is filled with sugar water, milk or fruit juice -carbohydrate ferments to organic acids demineralizing the tooth enamel until it decays. -advise parents never to put their baby to bed with a bottle -encourage to fill bottle with 52 water and use a nipple with a smaller hole to prevent the baby from receiving a large amount of fluid. -if refuses to drink anything but milk, dilute the milk with water more and more each night until the bottle is down to water only. 52  Neonatal Common Health Problems Dyssomnia Trouble falling or staying asleep at night Sleep Difficulty staying awake during the day Parasomnia confusional arousal, sleepwalking, nightmares problems Intervention Parental presence at bedtime establish bedtime rituals Placing infant awake in his own crib Do not use crib as playpen 20XX presentation title 53 Sleep Problems Safe sleep: Do not place the infant on his abdomen while sleeping (prone)- associated with SIDS (sudden infant death syndrome) Definition 1. Dyssomnias: the child has trouble either falling or staying asleep at night, or has difficulty staying awake during the day. 2. Parasomnias : are characterized as confusional arousals, sleepwalking, sleep terrors, nightmares, and rhythmic movement disorders; these typically occur in children 3 to 8 years old Intervention -careful assessment is essential -"Let the child cry until falling asleep," is difficult to 53 implement and inappropriate for certain conditions -parental presence at bedtime -nurses must discuss infant sleep problems with the mother (and family) in addition to other developmental aspects of newborn care. encourage parents to establish bedtime rituals that do not foster problematic patterns. -placing infants awake in their own crib -the bed should be used for sleeping only, not as a playpen -advisable not to hang playthings over or on the bed; in this way the child associates the bed with sleep, not with activity. 53 THANK YOU KEEP BELIEVIN’ 54