LS CH 6 Prenatal Period to 1 Year.pdf

7589_Ch06_069-096 29/08/17 12:03 PM Page 69 CHAPTER 6 Prenatal Period to 1 Year Key Words Chapter Outline acrocyanosis Apgar score apnea attachment blastocyst bottle-mouth syndrome cervix chromosomes circumcision cleft palate colostrum conception conscience deciduous teeth dental caries dilatio...

7589_Ch06_069-096 29/08/17 12:03 PM Page 69 CHAPTER 6 Prenatal Period to 1 Year Key Words Chapter Outline acrocyanosis Apgar score apnea attachment blastocyst bottle-mouth syndrome cervix chromosomes circumcision cleft palate colostrum conception conscience deciduous teeth dental caries dilation dominant genes effacement embryo engrossment fertilization fetus fine motor skills fontanels genes gross motor skills involution karyotype lanugo meconium milia molding mongolian spot morula Heredity Genetic Counseling Environment The Prenatal Period Physical Characteristics Head and Skull Length and Weight Skin Genitals Face Abdomen Extremities Neurological Characteristics Vital Signs Developmental Milestones Motor Development Gross Motor Skills Fine Motor Skills Psychosocial Development Attachment Temperament Parental Guidance key terms continue on page 70 Cognitive Development Moral Development Communication Nutrition Breastfeeding Bottle Feeding Weaning and Introduction of Solid Foods Sleep and Rest Play Safety Health Promotion Summary Critical Thinking Multiple-Choice Questions Learning Objectives A t th e e n d of th i s ch ap te r , y ou s h ou l d b e ab l e to: • • • • • • • • • • • List three factors that promote a healthy pregnancy. Name four factors that may have an adverse effect on pregnancy. Describe the steps in prenatal development from fertilization to implantation. Describe physical development for infants from 1 to 2 months. Describe skin manifestations such as vernix caseosa, lanugo, mongolian spots, milia, and acrocyanosis. List five reflexes present at birth. Name the normal range for vital signs for the newborn. Compare the pattern of fine and gross motor skill acquisition. Give an example of cognitive development for this stage. State the process of language acquisition during infancy. Describe the nutritional needs of developing infants. objective continue on page 70 69 7589_Ch06_069-096 29/08/17 12:03 PM Page 70 70 Journey Across the Life Span Key Words (continued) neonate normal physiological weight loss nystagmus ovulation ova physiological jaundice placenta pseudomenstruation recessive genes sperm sudden infant death syndrome sutures teratogens umbilical cord vernix caseosa weaning zygote Learning Objectives • • • • • • (continued) Describe the advantages and disadvantages of breastfeeding and bottle feeding. Distinguish between the stools of breastfed and formula-fed infants. State the normal sleep patterns for the neonate. List three interventions used to promote infant safety. Name the immunization schedule for the newborn. List two concerns for health promotion during the infancy period. HEREDITY Two factors that have a large influence on the health of the developing baby are heredity and environment. Each sperm and ovum contributes 23 chromosomes to the new entity, which is a single-celled zygote. The sex of the zygote is determined by the combination of X and Y chromosomes. The ovum always contains an X chromosome, whereas the sperm may contain either an X or a Y chromosome. If the ovum is fertilized by an X chromosome sperm, the zygote will be female; if a Y chromosome sperm fertilizes the ovum, a male zygote will result (Fig. 6.1). Chromosomes carry the genes, which transmit all the genetic information or hereditary characteristics from the parents to the child (Fig. 6.2). The genes are found on strands of deoxyribonucleic acid (DNA) within the nucleus of the cell. Some genes are dominant. Dominant genes are capable of expressing their traits over other genes. Recessive genes, however, can transmit their traits only if they exist in like pairs. If one gene of a pair is dominant and one is recessive, the dominant gene will exert its influence over the recessive gene. Eye color is an example of a trait that is affected by the dominant–recessive pattern of inheritance. In other words, if a brown eye color gene is paired with a blue eye color gene, the dominant brown gene will govern. More than 700 different diseases are the result of defects carried on recessive genes. Sickle-cell disease, Tay-Sachs disease, and hemophilia are some examples of recessive disorders. To inherit a recessive trait or disorder, the child must Father X Mother Y X X Baby boy Y X Y X X X Baby girl X X FIGURE 6.1 Schematic illustration of the sex of the fetus, which is determined at the time of conception. 7589_Ch06_069-096 29/08/17 12:03 PM Page 71 Prenatal Period to 1 Year FIGURE 6.2 Heredity characteristics can be easily seen in a family unit. inherit the recessive gene from both parents. The chromosomal structure of an entity is known as its karyotype. Karyotyping—mapping the chromosomal structure—can help predict the transmission of certain genetic disorders and is useful in counseling prospective parents. Genetic Counseling Genetic counseling may be suggested for individuals and couples so that they understand hereditary disorders, their risk, and measures to prevent and treat these disorders. Genetic screening for certain diseases should be considered for individuals of specific cultural descents, such as sickle-cell disease in African Americans and Tay-Sachs disease in European Jewish descendants. Genetic counseling includes the entire family and is a long process that may take weeks for results. A common blood sample test may be done for genetic testing. Prenatal testing includes chorionic villus sampling, umbilical cord sampling, amniocentesis, carrier detection, and ultrasonography. Amniocentesis is done only if further testing is needed. Postnatal diagnosis may be determined using physical examination, chromosomal and DNA analysis, and other testing. Health care workers can be most helpful in supporting families during this process by guiding them to select healthy lifestyle choices. Advising patients to follow a proper diet and avoid smoking and alcohol use may help lead to positive outcomes. ENVIRONMENT From the moment life begins, the environment begins to exercise its influence on the newly formed 71 entity. Good health practices contribute to the development of a healthy baby. The quality of the mother’s diet affects her health and that of her baby. A balance of rest and exercise is crucial for a healthy pregnancy. As a rule, a woman can continue any exercise that she has regularly participated in before her pregnancy. Walking is the best exercise during pregnancy, and women should be encouraged to walk daily. Before beginning any new form of sport or exercise, the pregnant woman should check with her physician. Both harmful and life-sustaining substances are transmitted from the mother to the developing baby through the placenta. Chemical or physical substances that can adversely affect the unborn are known as teratogens. Tobacco, alcohol, and many drugs are teratogens. As soon as a woman starts to try to become pregnant, she should eliminate all known teratogens to reduce the risks associated with these substances. Bacterial, protozoan, and viral infections may also damage the fetus. The rubella virus presents great risk to the fetus if the woman contracts it during her pregnancy. This virus has been shown to cause serious fetal abnormalities. HIV may also be transmitted to the unborn child. Toxoplasmosis, a common parasite found in many animals, may cause harm to the developing fetus if contracted by the pregnant woman. Pregnant women may avoid this condition by eating well-cooked meats and by avoiding contact with cat litter. Pregnant women should avoid any intake of any alcohol during the course of their pregnancy. Alcohol by-products can cross the placental membrane and fetal blood–brain barrier. Ingestion of alcohol during the first trimester appears to present the greatest risk for developing fetal alcohol syndrome (FAS). Miscarriages, stillbirths, prenatal and postnatal growth restriction, and central nervous system abnormalities are some of the problems associated with FAS. Prevention and education are key to eliminating these abnormalities. Early detection of FAS and proper intervention may assist the child in reaching his or her full potential. Cigarette smoking has also been shown to have teratogenic effects on the unborn. Both low birth weight and growth restriction have been linked to smoking during pregnancy. The mother should avoid pesticides, chemicals, radiation, and other environmental hazards because of their teratogenic effects. The pregnant woman must follow good health practices and have close medical supervision to ensure her own and her child’s health and well-being. 7589_Ch06_069-096 29/08/17 12:03 PM Page 72 72 Journey Across the Life Span THE PRENATAL PERIOD The period from fertilization to birth is called the prenatal period. From the time of menarche in puberty until menopause in middle age, the female ovaries produce ova, or female sex cells. Roughly every 28 days an ovum matures and is released in a process known as ovulation. From puberty on, the male testes produce sperm, or male sex cells, which are released at the moment of ejaculation. Pregnancy begins with the union of the female ovum and the male sperm cell. This is known as conception or fertilization; all inherited characteristics are determined at this moment. After fertilization, which normally takes place in the woman’s fallopian tube, the zygote undergoes a series of cell divisions and forms a cell mass known as a morula. The morula continues to divide and change as it travels down the fallopian tube to the uterus, where it implants itself in the uterine wall. At the point of implantation the entity is called a blastocyst. The total process, from fertilization to implantation, takes about 7 days (Fig. 6.3). After implantation, the multicelled structure, now referred to as an embryo, continues to develop. By the end of the eighth week of development, all essential structures are formed and the embryo is now termed a fetus. The estimated length of pregnancy is approximately 40 weeks (9 calendar months or 10 lunar months). Prenatal development may be divided into three stages: pre-embryonic, embryonic, and fetal. The pre-embryonic stage begins with fertilization First cell division (zygote) and lasts for about 2 weeks. The embryonic stage begins 2 weeks after fertilization and ends after the eighth week. The fetal stage begins with the ninth week and ends with the birth of the baby. A summary of the process of fetal development is shown in Figure 6.4. Approximately 280 days after conception, labor begins (Fig. 6.5). Several different hormones are believed to be involved in the process of labor, including progesterone, oxytocin, and prostaglandins. Progesterone is produced by the ovaries (female sex glands). It is the hormone that maintains pregnancy and helps stimulate uterine contractions at the end of the pregnancy. Oxytocin is produced by the hypophysis, the posterior lobe of the pituitary gland. Oxytocin has two functions: It stimulates uterine contractions and prepares the breasts for breastfeeding. Prostaglandins are hormones that are produced in various tissues throughout the body. Like oxytocin, uterine prostaglandins help stimulate contractions. The labor and delivery period has three distinct stages. Stage 1, the stage of dilation, is usually the longest, lasting an average of 12 to 24 hours. This stage begins with the onset of regular rhythmic uterine contractions and ends with the complete dilation (widening) of the cervix (the lower portion of the uterus). During this stage, effacement, or a shortening and thinning of the cervix, occurs. Stage 2, the expulsion stage, lasts about 11⁄2 hours, but it is the most difficult stage. It begins with the complete dilation of the cervix and ends with the birth of the baby. Stage 3 is the shortest stage, lasting from 5 to Continuing cell division Morula Blastocyst Fertilization Implantation Ovulation FIGURE 6.3 Ovulation, fertilization, and implantation. 7589_Ch06_069-096 29/08/17 12:03 PM Page 73 73 Prenatal Period to 1 Year Week 4 End of first lunar month Weeks 6– 8 Second lunar month Weeks 9– 12 Third lunar month Weeks 13–16 Fourth lunar month Length: ¼ in. (0.6 cm) Weight: Appearance: Curled upon itself with head touching tail. Signs of formation of arm and leg buds. Liver formed. Heart present. Begins to pulsate about the 14th to 24th day. Primitive blood cells present. Beginnings of brain present. Length: 1 in. (2.5 cm) Weight: 1/30 oz (1 g) Chambers of heart develop. Rapid brain development occurring. Primitive limbs present. Fingers and toes begin to form. Face develops. Eyes, ears, nose appear. Palate and upper lip forming. Gastrointestinal tract developing. Part of intestine still in umbilical cord. Urogenital systems forming. Head disproportionately large due to rapid brain development. Organogenesis completed. Length: 3 in. (7.5 cm) Weight: 1 oz (28 g) Growth and maturation of structures continues. Head disproportionately large. Brain shows structural features. Eyelids fused. Nail beds form on fingers and toes. Bile present in intestines. Spontaneous movements present. Ossification centers in bones begin to appear. Enamel-forming cells and dentin forming. Kidney secretion by 10th week. Bone marrow begins to form blood cells. Distinguishing sexual traits evident. Respiratory-like movements (reflex activity) present. Intestines retracted from umbilical cord into abdomen. Palate completed fused. Neck well defined. Length: 6 to 7 in. (15.2 to 17.7 cm) Weight: 4 oz (112 g) Fetus active. Mother may experience quickening. Skeleton calcified and visible on x-ray film. Downy lanugo on head. Placenta distinct. Blood vessels visible beneath transparent skin. Heart actually circulating blood through fetal body. Increasing amount of respiratory movements can be detected by sonogram. Enzymes ptyalin and pepsin being secreted. Fetal thyroid gland begins functioning by the 14th week. Total body blood volume: Less than 100 mL. Amount of amniotic fluid present: 150 to 280 mL. FIGURE 6.4 Fetal development. Continued 7589_Ch06_069-096 29/08/17 12:03 PM Page 74 74 Journey Across the Life Span Weeks 17– 20 Fifth lunar month Length: 10 in. (.5 cm) Weight: 8 to 10 oz (224 to 280 g) Fetal heart sounds evident with stethoscope. Scalp hair visible. Lanugo present, especially on shoulders. Skin less transparent. Eyebrows present. Vernix caseosa present. Fingernails and toenails apparent. Some fat deposits present. Weeks 21– 24 Sixth lunar month Length: 12 in. (30.5 cm) Weight: 1-1/2 lb (672 g) Skin wrinkled, pink, translucent. Increasing amounts of vernix caseosa present. Eyebrows and eyelashes well defined. External ear soft, flat, shapeless. Lanugo covering entire body. Some breathing effort evident. Weeks 25– 28 Seventh lunar month Length: 15 in. (37.5 cm) Weight: 2-1/2 lb (1120 g) Skin red, wrinkled, covered with vernix caseosa. Looks like a “little old man.” Membranes disappear from eyes. Eyelids open. Scalp hair well developed. Fingernails and toenails present. Subcutaneous fat present. Testes at internal inguinal ring or below. Weeks 29–32 Eighth lunar month Length: 15 to 17 in. (37.5 to 42.5 cm) Weight: 3-1/2 to 4 lb (1568 to 1792 g) Skin pink and smooth. Areola of breast visible but flat. Testicles begin descent down inguinal canal (may be in scrotal sac), or Labia majora small and separated, clitoris prominent. Hair fine and wooly. One or two creases evident on anterior portion of soles. Deposits of subcutaneous fat present. Can be conditioned to respond to sounds outside of mother’s body. Weeks 33–36 Ninth lunar month Length: 19 in. (47.5 cm) Weight: 5 to 6 lb (2240 to 2688 g) Increased fat deposits give body and limbs a more rounded appearance. Skin thicker, whiter. Lanugo disappearing. Sole creases involve anterior two thirds of foot. Breast tissue develops beneath nipples. Weeks 37–40 Tenth lunar month FIGURE 6.4—cont’d Length: 20 in. (50 cm) Weight: 7 to 7-1/2 lb (3136 to 3360 g) After 38 weeks, considered full term. Body plump. Lanugo gone from face. Vernix caseosa disappearing, present in varying amounts. Testes in scrotum, or Labia majora meet in midline and cover labia minora and clitoris. Ear well defined. Erect from head. Uniform color to eyes (a slate hue). Acquires antibodies from mother. 7589_Ch06_069-096 29/08/17 12:03 PM Page 75 Prenatal Period to 1 Year FIGURE 6.5 Length of labor and birth vary with each individual. 30 minutes. It begins with the birth of the baby and ends with the delivery of the placenta. The exact length of time for these three stages varies with the individual. Factors such as the number of previous pregnancies and deliveries affect the duration of each stage. The culture and society to which individuals belong help influence childbirth practices and beliefs. Childbirth practices in Western civilization have changed over time. Before the mid-19th century, childbirth was a family event that took place at home. After the Industrial Revolution, childbirth shifted from the home to hospital-centered care. Physicians were the primary caregivers. Gradually, the natural childbirth movement evolved and became popular. This resulted in a decreased use of medications and instruments and a shift to familycentered care. Today many hospitals have birthing centers, which attempt to povide comfort in an “at home” atmosphere. In addition, some individuals have selected to give birth at home, often under the care of a midwife, with their family playing an active part in their birth experience. Education, preparation, and support are necessary to make the childbirth experience a safe and positive one for all involved. During pregnancy, a protective sac of fetal membranes surrounds the developing fetus. Amniotic fluid fills the sac. Amniotic fluid acts as a protective cushion, maintains even body temperature, allows for movement of the fetus, and provides a fluid source for the fetus. Mother and fetus are linked through an organ called the placenta. During pregnancy this structure serves many functions, 75 including producing hormones, transporting nutrients and wastes, and protecting the baby from harmful substances. The umbilical cord is the link between the fetus and the placenta. At birth it appears to be whitish blue and is covered by a glistening membrane. In the delivery room the cord must be assessed for the presence of three vessels—two arteries and one vein. Any deviation from this usually indicates some serious cardiac abnormality. In fetal circulation, oxygen and nutrients reach the fetus by way of the umbilical vein, and waste and deoxygenated blood return to the placenta for oxygenation by way of the umbilical arteries. Fetal circulation ends at birth, when the umbilical cord is tied off and the newborn infant, or neonate, takes its first breath. At 1 minute after birth, and again 5 minutes later, the neonate is assessed and given an Apgar score (Table 6.1). Five essential categories of functioning are assessed, including color, reflex irritability, heart rate, respiratory rate, and muscle tone. The Apgar score gives an immediate clinical picture of the newborn’s overall status. PHYSICAL CHARACTERISTICS Head and Skull At birth the newborn’s head is large in proportion to the rest of its body, typically one-fourth of the total body length. A newborn’s average head circumference is 13 to 14 inches (33 to 35.5 cm)— about 1 inch larger than the chest. The head circumference increases by about 3 inches during the first 8 months of life. The skull consists of six soft bones: one occipital, one frontal, two parietal, and two temporal bones (Fig. 6.6). The skull bones are separated by bands of cartilage, called sutures. Located at the anterior and posterior of the infant’s skull are two spaces or soft spots, called fontanels. These fontanels are very visible and even appear to pulsate when the infant cries. The skull should be palpated for the presence of sutures and fontanels. The small triangular-shaped posterior fontanel closes by the infant’s fourth month. The larger, diamond-shaped anterior fontanel closes when the child is 12 to 18 months old. These spaces allow the skull to accommodate the rapid brain growth that takes place in this period. The newborn’s skull may appear misshapen or elongated as a result of molding, which occurs as the head passes through the narrow birth canal. This is a temporary condition that disappears naturally in a few days. 7589_Ch06_069-096 29/08/17 12:03 PM Page 76 76 Journey Across the Life Span T A B L E 6.1 A pga r Sc or i n g C h ar t Sign 0 1 2 1 minute 5 minutes Heart rate (beats per minute) Absent <100 >100 — — Respiratory rate (breaths per minute) Absent Slow, irregular Good, crying — — Muscle tone Limp Some flexion of extremities Active motion — — Reflex irritability: Catheter in nostril No response Grimace Cough or sneeze — — Slap to sole of foot No response Grimace Cry and withdrawal of foot — — Color Blue, pale Body pink; extremities blue Completely pink — — Frontal suture Frontal bone Anterior fontanel Parietal bone Sagittal suture Posterior fontanel Occipital bone FIGURE 6.6 Infant’s skull showing sutures and fontanels. FIGURE 6.7 Physical characteristics of the newborn include a short neck and tightly flexed limbs. Length and Weight The average length of the newborn measured from head to heel is 20 inches (50 cm). Normal length for newborns ranges from 19 to 21 inches (48 to 53 cm). Usually, infants grow 1 inch per month for the first year. At 12 months the child’s brain is approximately 2.5 times as big as it was at birth, the head and chest are equal in circumference, and the child is 1.5 times longer than at birth. The newborn’s head appears to rest on its chest because its neck is short and has deep creases (Fig. 6.7). The arms and legs are proportionately short and kept in a tightly flexed position. At birth, the newborn weighs an average of 7.5 pounds (3,400 g); the normal range is from 5.5 to 10 pounds. Boys are generally slightly larger than girls at birth. The newborn loses 5% to 10% of its birth weight in the first few days of life. This occurs because the infant is given nothing by mouth for the first few hours and, therefore, the infant’s output exceeds its intake. This is known as normal physiological weight loss. When the mother’s breast milk comes in or formula feeding begins, the neonate regains its initial weight loss in approximately 10 days. Thereafter the newborn will gain 5 to 6 ounces per week for the first month; infants will double their birth weight by 5 to 6 months of age and triple their birth weight by 7589_Ch06_069-096 29/08/17 12:03 PM Page 77 Prenatal Period to 1 Year their first birthday. Approximately 75% of an infant’s body weight consists of water. For this reason infants with vomiting and diarrhea may suffer a rapid loss of total body fluid and possible dehydration. Skin The newborn’s skin at birth is thin and appears pale. Some temporary acrocyanosis (blueness of the hands and feet) may be present as a result of poor peripheral circulation; this is usually transient and disappears a few hours after birth. Pigmentation may be more pronounced in certain areas of the body, such as the earlobes, scrotum, and back of the neck; full pigmentation develops several days later. The neonate’s color varies according to the amount of melanin present in the skin. In general, infants of northern European descent vary from pink to red; infants of African descent vary from pink to dark red; infants of Asian descent vary from rosy red to yellowish tan; those of Hispanic and Mediterranean descent may be yellowish brown; and Native American infants vary from light pink to reddish brown. Infants with relatively more melanin in their skin may be born with a mongolian spot, a flat, irregular, pigmented area in the lumbar-sacral region. The mongolian spot usually fades and becomes less noticeable at about age 4. Many newborns have a covering of fine hair over the body. This covering, known as lanugo, vanishes in the first few days after birth. The newborn’s skin creases have a white, cheeselike, oily covering called vernix caseosa, which protects the fetus’s skin during pregnancy. Milia, small clusters of pearly white spots mostly on the infant’s nose, chin, and forehead, may also be present at birth. These spots are caused by the retention of sebaceous material within the sebaceous glands and disappear spontaneously without treatment. Some infants develop a yellow tinge to their skin known as icterus neonatorum, or physiological jaundice. Physiological jaundice frequently occurs in newborns within 48 to 72 hours after birth. At birth the neonate’s red blood cell (RBC) count is higher than that of the normal adult—usually 6 million per mm3 of blood. A few days after birth the RBC count begins to decrease as the body destroys these unnecessary excess cells. This releases a high amount of bilirubin (a component of RBC), producing the jaundiced appearance in the infant. Physiological jaundice should not be confused with jaundice related to blood incompatibilities, which is usually present immediately at birth and requires prompt medical intervention and treatment. 77 Genitals Maternal hormones of pregnancy present in the neonate’s bloodstream may cause certain physiological anomalies. The breasts of neonates of both sexes may be swollen. This condition will disappear without intervention. The scrotum of male neonates may appear large and edematous. The scrotum should be palpated for the presence of testicles, which usually descend from the abdominal cavity into the scrotal sac during the seventh month of fetal life. If the testicles have not descended, the infant will be observed to see if descent occurs over the next few months. Undescended testicles can be treated with a short course of drug therapy or surgery. The newborn’s penis is inspected for the location of the urethral opening. Normally this opening is just at the tip of the head of the penis under the foreskin. Circumcision, the surgical removal of the foreskin, may be performed after birth for hygienic or religious reasons. Any deviation should be noted and reported to the physician for follow-up treatment. The labia in the newborn female may appear swollen. A blood-tinged mucous vaginal discharge known as pseudomenstruation may be noted. These conditions are related to maternal hormones and disappear without treatment. Urine is normally present in the bladder at the time of birth. The newborn should void within 24 hours after birth and 8 to 10 times a day thereafter. The initial voiding may appear rust-colored because of the presence of uric acid crystals. This condition generally disappears without treatment. Face The newborn’s face is small, and the eyes may appear swollen. The eyes are treated after birth with antibiotic application of erythromycin or silver nitrate as a preventive against blindness caused by gonorrhea. Eye color varies from slate gray to dark blue. Permanent eye color is not determined until 3 to 6 months of age. No tears are produced until 4 weeks of age, when the lacrimal ducts (tear ducts) are developed. The neonate usually has a flat nose and a receding chin. The neonate’s mouth is usually examined closely for any defects or abnormalities, particularly cleft palate, the incomplete formation and nonunion of the hard palate. This condition can be corrected through surgical repair. The gums should be pink and moist. The first teeth, called deciduous teeth or primary teeth, begin to erupt when the infant is 7589_Ch06_069-096 29/08/17 12:03 PM Page 78 78 Journey Across the Life Span H E L P F U L H I N T S To hasten cord healing, fold diapers away from the cord stump, apply alcohol to the area around the cord, and report any signs of redness or drainage to the pediatrician. 1 Central incisor 2 Lateral incisor 3 Cuspid 4 First molar 5 Second molar (Upper) (Lower) 8–12 mos. 5–9 mos. 8–12 mos. 12–18 mos. 18–24 mos. 12–18 mos. 24–30 mos. FIGURE 6.8 Approximate ages for the eruption of deciduous teeth. about 6 or 7 months old (Fig. 6.8). Usually the first teeth to appear are the two lower central incisors; they are followed by the two upper central incisors. By age 12 months the baby will have about six or eight teeth. Abdomen The neonate’s abdomen appears large and flabby. Immediately after birth the umbilical cord is tied and cut. After a few days the blood vessels of the cord become dry or thrombosed. This is accompanied by a change in color from dull yellowish brown to black. By the tenth day the dried cord falls off and the navel is completely healed. Tub bathing is avoided until the navel is fully healed. At the time of birth the newborn can swallow, digest, metabolize, and absorb nutrients. The newborn can metabolize only simple carbohydrates. For this reason, whole milk, which contains complex sugars, is not given to the newborn. The newborn’s stomach can hold 1 to 3 ounces of fluid; by 10 months, it can hold about 10 ounces. The neonate’s cardiac sphincter is underdeveloped; therefore, it is important to allow the infant short periods of feeding, followed by “bubbling” or burping for the release of swallowed air. Bowel movements of healthy infants vary in number, color, consistency, and general appearance. The H E L P F U L H I N T S Do not use liquor or apply aspirin to the teething infant’s irritated and swollen gums. mother’s diet or the type of formula given will also influence the infant’s stools (Table 6.2). Within 10 hours after birth the newborn should pass his or her first stool, known as meconium. Meconium is thick, green–black, tarry, and odorless. Breastfed infants have stools that resemble light, seeded mustard. Stools of formula-fed infants are commonly semisolid and tan or yellowish in color. Some infants have four to six bowel movements a day. An infant is constipated if stools are very hard and can be passed only with much effort. Adding some additional water or strained fruits to the diet may prevent constipation. Extremities The newborn’s extremities are short in proportion to the rest of the body and are kept in a tightly flexed position. They should be examined for range of motion, symmetry, and reflexes. The lower extremities are examined closely to determine if there is an extra gluteal fold, which usually indicates a congenital hip dysplasia (Fig. 6.9). Any abnormality should be reported immediately to the physician for further evaluation. The toes and fingers are counted and inspected for abnormalities. In full-term infants the soles of the feet and palms of the hands are deeply creased. Preterm infants have only very fine lines on their palms and soles. NEUROLOGICAL CHARACTERISTICS A neurological assessment in the newborn focuses on reflexes, posture, movement, and muscle tone. At birth the nervous system is immature, and the newborn responds to his or her environment through a series of reflexes. The presence of certain reflexes indicates a normal neurological system and also helps estimate gestational age. Several reflexes are protective; these include blinking, sneezing, swallowing, and the gag reflex. Other reflexes present include Moro, or startle, reflex; rooting; grasp; Babinski; and tonic neck reflex. Rooting and sucking help the infant secure food. Table 6.3 describes these reflexes in detail. 7589_Ch06_069-096 29/08/17 12:03 PM Page 79 Prenatal Period to 1 Year T A B L E 6.2 St ool P at t er n s f or N ew b or ns Stool Age Description Meconium First 2 days Greenish-black, tarry, odorless Transitional 2–3 days Brown to yellow to green Formula-fed From day 2 or 3 Pasty yellow or tan, distinct odor Breastfed From day 2 or 3 Light, seeded mustard, sweet odor The newborn’s spinal column is inspected to make certain that there are no masses, cysts, or openings. The presence of any spinal defect necessitates immediate medical intervention. The five senses (sight, hearing, taste, touch, and smell) are present at birth and function at a primitive level. Neonates can track objects at birth; they appear to prefer bright lights and yellow, green, and pink objects and large geometric shapes. The neonate’s A 79 pupils react to light by dilating and contracting. The newborn’s vision is 10 to 30 times less acute than normal adult vision of 20/20. By the time the infant is 6 months old, vision should be 20/100 or better. Movement of the eyes is usually unequal owing to immature cilliary muscles; it is not uncommon for a neonate’s eyes to cross or for one eye to drift when focusing on an object. This is known as nystagmus. These deviations are temporary and should disappear without treatment. By 4 months of age infants have binocular vision: They can focus both eyes simultaneously to produce one image. Depth perception at first is limited to grasping for items out of reach and becomes more precise at about age 7 to 9 months. At this point the infant is able to reach for items more accurately and purposefully. The ears are positioned on the sides of the head, with the top of the ear about the level of the eyes. At birth the newborn’s ears are generally filled with either vernix or birth fluid, which dissolves within a few days. The infant hears and responds to loud, lowfrequency sounds. A sudden loud sound will produce a startle response. By the age of 6 to 8 weeks, infants recognize their mother’s voice and turn their heads in response to it. A 1-year-old child can discriminate between different sounds and often recognize the source. B FIGURE 6.9 Assessment of the gluteal and popliteal folds of the hips. The folds should be symmetrical. A: Limited abduction. B: Asymmetry of the shin folds. 7589_Ch06_069-096 29/08/17 12:03 PM Page 80 80 Journey Across the Life Span T A B L E 6.3 Re fl e x es Pr es en t i n t h e N or m al Neo nate Reflex Action Disappearance/Extinction Moro Sudden movement or jarring of position causes extension and adduction of extremities. By age 3 or 4 months Tonic neck If head of back-lying newborn is turned to one side, infant will extend arm and leg on that side. By age 5 months Rooting When newborn’s cheek is gently stroked, infant turns toward that side and opens mouth. By age 4 to 6 months Sucking Newborn makes sucking movements when anything touches lips or tongue. Diminishes by age 6 months Babinski When newborn’s sole is stroked, toes hyperextend and fan outward; big toe turns upward. By age 3 months Palmar grasp Newborn briefly grasps any object placed in hands. By age 3 months (present from age 6 weeks) Newborn infants can discriminate among different tastes. If they are given a sweet solution, they will begin to make sucking movements. When given something sour, they will respond with a grimace or pout. The 1-year-old child has developed a capacity to taste and has preferences for certain flavors. The sweet taste appears to be universally pleasing. The young child should be introduced to a wide variety of tastes and textures. This exposure helps to mature the child’s sense of taste. The sense of touch is keenly present at birth. The face is most sensitive, especially around the mouth. The hands and soles of the feet are also sensitive. Infants like to be touched and rocked because of the calming effect. Pain perception is present in the newborn and is witnessed when an injection is given. The typical reaction to pain is loud crying and thrusting the whole body and extremities. The 1-year-old child demonstrates withdrawal from pain but may not be able to recognize the source of the pain. For example, the child may touch a hot pot and quickly respond by withdrawing the hand and crying. However, the child might repeat the action another time, not understanding the cause and effect. Studies indicate that newborns have a sense of smell. Newborns have been tested and found to react to strong odors by turning away. It has also been documented that newborns can recognize the smell of breast milk. One study showed that infants can even distinguish their own mother’s breast milk from that of others. VITAL SIGNS The newborn’s temperature immediately after birth may be slightly below normal. This is a result of an immature temperature-regulating mechanism and heat loss caused by the cooler environment in the delivery room. The newborn should be dried off and placed under a radiant warmer to help raise his or her body temperature. In addition, the neonate’s head should be covered to prevent further heat loss from evaporation. Once stabilized, the neonate’s normal axillary temperature ranges from 97.7°F to 99.5°F (36.5°C to 37.5°C). The newborn’s temperature should be measured using the axillary route to prevent possible rectal perforation. Pulse should be taken by listening to the chest for an apical pulse for 1 full minute (Fig. 6.10). The apical heart rate ranges from 120 to 160 beats per minute. Slight variations in the heart rate are common. During periods of rest the rate may slow down to 100 beats per minute; during crying periods the rate may increase to 180 beats per minute. Blood pressure (BP) readings provide a baseline and can be used to assess the infant for cardiac abnormalities. Average BP using oscillometry (Dinamap) is 65/40 mm Hg. Blood pressure will increase and heart and respiratory rate will decrease as the child gets older. Respirations should be counted for 1 full minute. The respirations of the newborn are normally irregular, shallow, and diaphragmatic, with brief periods of apnea (absence of breathing). Infant respirations 7589_Ch06_069-096 29/08/17 12:03 PM Page 81 Prenatal Period to 1 Year 81 the infant to rise up on all four limbs. Some infants progress to this style of locomotion by 10 to 11 months. At about 8 months babies can pull themselves up to a standing position. Standing is followed by cruising, which is a form of stepping while holding on to some object or surface for support. Walking unassisted is achieved between the ages of 12 to 15 months (Fig. 6.11). FIGURE 6.10 The newborn is measured and identified before leaving the delivery room. can be counted by watching the abdomen rise and fall. The normal respiratory rate is 30 to 60 breaths per minute. Marked deviations in these normal ranges may indicate congenital abnormalities and warrant further investigation. DEVELOPMENTAL MILESTONES Motor Development The neonate’s movements and behavior appear purposeless and uncoordinated, but all newborns have distinct behavioral characteristics and physical traits that make them different from other neonates. Every infant has his or her own growth timetable. Growth and development should be assessed based on the infant’s own individual progress. Gross Motor Skills Gross motor skills are movements of the large muscles of the arms and legs. Following a cephalocaudal pattern, head control develops by 2 months; by 3 months the infant can briefly hold its head up. At 4 months the infant can raise the head to a 90-degree angle from the prone position. Rolling over from the abdomen to the back occurs at 4 months. By 6 months old, the baby can roll both ways, sit with support, and hold the head erect. Sitting alone occurs at the seventh month. The 10-month-old infant can change position from the prone (facedown) to the sitting position. Crawling, a primitive movement in which the infant’s abdomen is on the floor, is usually achieved by infants at about 9 months. Creeping is a more advanced form of movement that requires Fine Motor Skills Fine motor skills include the movements of the hands and fingers. Initially, grasp is actually a reflex action involving the whole arm in a swiping movement. The neonate exhibits the palmar grasp reflex, grabbing any object that is placed in the hands. Finger and hand control develop after shoulder and arm control, demonstrating the principle of proximodistal development. Purposeful reaching and grasping using the whole hand occur by the fifth month of life. It is common to see infants take hold of objects and immediately bring them to their mouths. For this reason, it is important that safety measures be taken to prevent accidental aspiration of small objects. The 6-month-old infant is able to hold a bottle, a cracker, or dry toast and bring it to the mouth. At this stage of development, many babies enjoy biting on a hard food object; this can be soothing to their swollen gums. Hand preference usually does not appear until the seventh or eighth month, when the baby can transfer an object from one hand to the other. The 7-month-old infant continues to make progress with self-feeding. He or she can hold the bottle and now has the use of the pincer grasp, which permits the opposition of thumb and forefinger. At this time it is typical for babies to grasp and then release small objects. This action usually delights the child because it causes the caregiver to retrieve the object so the action can be repeated. By 9 months, babies are able to drink from a cup and attempt to use a spoon. In early attempts, the spoon may be inverted and the contents spilled. The 1-year-old child can hold a writing object, make scribbling marks on paper or other surfaces, and build a tower of two blocks. Psychosocial Development Erik Erikson believed that each child needs to accomplish a particular task at each stage of development. The resolution of each task permits the child to move on to a new stage. For an overview of Erikson’s stages of growth and development, refer to Chapter 5. According to Erikson, the infant is working on completing the task of trust. The infant 7589_Ch06_069-096 29/08/17 12:03 PM Page 82 82 Journey Across the Life Span 2 months: Controls head 10 months: Creeps 3 months: Sits with support 7 months: Sits alone 9–11 months: Stands with support 12–15 months: Walks alone FIGURE 6.11 Developmental milestones. will feel secure and develop a sense of trust when the environment consistently satisfies his or her basic needs for food, comfort, and love. This first stage lays the foundation on which future stages will be built. Depriving the infant of basic needs can result in the development of mistrust and hinder the further development of the infant’s full potential. Attachment The parent–child relationship begins with fetal development and continues after birth. Emotional bonds between the mother and child are known as attachment (Fig. 6.12). This can be evidenced by the way the mother holds, talks to, and looks at the baby. This attachment, or bonding, process serves to strengthen the infant’s sense of security and self. This process is reciprocal between infant and parent. Bonding is felt by the parent during the first period of touching and gazing at the infant. Touch, skin to skin contact, and seeing the infant’s features as resembling other family members helps solidify this feeling of attachment. The process of bonding is referred to as engrossment. Bonding is as important to the father as to the mother. Encouraging fathers to participate in the pregnancy and birthing process can initiate the foundation for engrossment. After birth, bonding can be strengthened by involving the father in child care. FIGURE 6.12 Parent–child bonding. Temperament Babies are born with their own unique temperaments, which determine their moods and their responses to stimulation. Temperament is inborn, whereas personality is shaped and affected by the 7589_Ch06_069-096 29/08/17 12:03 PM Page 83 Prenatal Period to 1 Year 83 environment. An infant’s willingness to interact with others is a part of his or her temperament. Some babies are very social, and others are shy. Babies with difficult temperaments are more fretful and cry a lot. These infants are not easily soothed. Other infants have an even temperament, which allows them to adapt to their surroundings with little fussing. Parental Guidance As infants begin to develop their means of locomotion, the need for discipline increases. For the first 6 months parents may use the art of distraction. The baby who continues to look and reach for the knobs on the stove can be given an age-appropriate toy as a substitute. In the second 6 months, as the infant’s memory and cognition increase, discipline must be more direct. The 10-month-old infant can be told “No” firmly when he or she reaches for something unsafe. The child at this stage is able to understand the tone of repeated admonitions. Verbal cues alone without supervision cannot prevent accidents. Parents and caregivers must be advised that discipline should not be harsh and should focus on praising the positive, desirable behavior while deemphasizing the negative, undesirable behavior. An important goal of discipline is to teach the child impulse control and to set limits. The need for discipline will expand and continue throughout childhood and into adolescence. Cognitive Development Piaget proposed that the infant begins life with no understanding of the world. The child then must learn about the environment through observation and sensory perception. For example, the baby begins to understand objects by touching, tasting, seeing, hearing, and smelling. See Figure 6.13. Piaget described infancy as the stage of sensorimotor development. Initially, infants respond to stimuli in the environment by reflex action. At about 8 months, infants begin to plan and coordinate their actions. For example, the infant knows that if he or she shakes a toy, it will produce a sound. By the end of the first year, infants are able to form bonds with certain people and recognize and attach meaning to objects. They begin to be able to understand some repeated actions. For example, the 10-month-old infant has learned that when mother goes to the pantry or refrigerator, she might be getting something to eat. This learning is stored, and when it is repeated, it helps to develop the child’s ability to think. FIGURE 6.13 Infants learn about the environment through observation. Moral Development Moral development is not present at birth; the infant has no conscience, or system of values. The motivational forces guiding behavior are based on satisfaction of needs rather than moral beliefs. Infants do what pleases them and are not aware that their acts can affect others. They react to pain and love, and they judge behavior on the basis of how it affects them. Communication The infant at birth communicates primarily by crying to make needs known. Studies indicate that crying has different sounds and meanings. Differences can be noted in the type and amount of crying in newborn infants. Caregiver responses can decrease or increase the amount of an infant’s crying. Picking H E L P F U L H I N T S • Infants who cry fretfully with their fingers in their mouth are indicating hunger. • Infants who cry fretfully, draw their legs up in a flexed position, and pass flatus usually have colic. • Infants with a high-pitched, shrill cry usually have injury to the central nervous system. 7589_Ch06_069-096 29/08/17 12:03 PM Page 84 84 Journey Across the Life Span up an infant and holding, rocking, or using soothing sounds may decrease the amount of crying. Some cries may signal discomfort or pain. Determining and eliminating the source of the discomfort will lessen the crying. Before they acquire speech, infants communicate in other ways. At 2 months, the infant responds to familiar voices with pleasure and a smile. See Figure 6.14. Cooing or soft throaty sounds occur at 2 months. Later, the repetition of certain sounds becomes associated with objects or persons. This is known as babbling and is the use of consonants and vowels loosely connected. Babbling occurs between 3 and 6 months. The sequence of sounds made in babbling is universal. Disease affecting the infant’s mouth, tongue, and throat can delay babbling and language development. The 8-month-old child is able to imitate simple sounds such as “dada,” much to the parents’ delight. Other consonant sounds are more difficult; therefore, words like “mama” will be learned later. One-yearold children have an expressive vocabulary of about four to six words. They are able to understand the meaning of many more words by association with the objects or by tone of voice. Talking and reading to infants helps increase their language comprehension and verbal ability. All infants develop according to their own growth timetables. We have provided a rough timetable for each developmental skill for the first year of life. If marked delays in the acquisition of these skills are noted, parents should consult the physician for further evaluation. See Box 6.1 for a list of signs that should be discussed with the physician. NUTRITION Infants’ sucking, swallowing, and rooting reflexes enable them to search for and secure their food. The infant’s nutritional needs can be met during the entire first year by breastfeeding or by using ironenriched formula. Many factors influence the mother’s decision to breastfeed or bottle feed. Some of these factors include knowledge, support, financial considerations, cultural beliefs, and employment. In some cultures modesty or the belief that there is little value in colostrum influences some mothers to choose not to breastfeed. Teaching parents about breastfeeding advantages may help result in informed choices, but health care workers should ultimately support a woman’s decision about how to feed her baby. While breast milk is considered the best nutritional value for infants and is recommended, breastfed and bottle-fed infants thrive equally well. Table 6.4 lists the advantages and disadvantages of both feeding methods. Breastfeeding The American Academy of Pediatrics (AAP) and the U.S. Surgeon General recommend breastfeeding for at least the first 6 months of life. One immediate nutritional benefit of breastfeeding is the ingestion of colostrum. Colostrum is the precursor of breast milk and is present in the mother’s B O 6.1 X Sig ns o f Infant Dev elo pmental Delay Discuss the following with the physician: • Moro reflex persists after 4 months. • Infant does not smile in response to mother’s voice after 3 months. • Infant does not respond to loud sounds. • Infant does not reach or grasp by 4 months. • Infant still has tonic reflex after 5 months. • Infant cannot sit without help by 6 months. • Infant does not roll over in either direction by 5 months. • Infant does not stand by 11 months. • Infant cannot learn simple gestures such as waving bye-bye or shaking the head yes and no by 1 year. • Infant cannot point to objects or pictures by 1 year. FIGURE 6.14 Infants may respond with smiles and laughter. 7589_Ch06_069-096 29/08/17 12:03 PM Page 85 Prenatal Period to 1 Year 85 T A B L E 6.4 B r eas t f eed i n g V er s u s B ot t l e-Feed ing Breast Bottle No preparation required Requires preparation Inexpensive or free More costly Mother must be present, or milk must be expressed from breast in advance Frees up mother’s time Milk more easily digested; causes less gastrointestinal upset; less possibility of allergic reaction Formula not as easily digested as breast milk Low in saturated fat High in saturated fat Promotes bonding with mother, but does not allow other people to feed baby (except if pumped or formula is supplemented) Allows father to feed and bond with baby Baby gets immune factors from mother Mother’s diet does not affect baby Mother’s uterus contracts; involution hastened; menstruation delayed Amount baby ingests is not known Amount taken at each feeding can be readily determined breast as early as the seventh month of fetal life. It contains more protein, salt, and carbohydrate but less fat than regular breast milk. In addition to these nutrients, it contains immunoglobulins to help protect the newborn until its own immune system is more developed. Some infants are placed at the breast immediately in the delivery room (Fig. 6.15). This practice has a number of positive effects for both mother and infant. 1. It promotes bonding or attachment between mother and child. Early signs of bonding are evidenced by the face-to-face interaction between infant and caregiver. Other early signs of bonding include talking, smiling, and playing with the infant. 2. It hastens involution (return of the uterus to its nonpregnant state) by stimulating uterine contractions and helping to restore muscle tone in the uterus. 3. It promotes the production of colostrum. Actual breast milk appears on the third day after delivery; at this time the new mother will notice that her breasts are very firm or engorged. A visit with a lactation consultant can help new mothers learn FIGURE 6.15 The infant can be put to the breast immediately after delivery. how to successfully breastfeed their infants. Many hospitals provide consultations before the mother is discharged from the hospital. Bottle Feeding Mothers who cannot or do not wish to breastfeed can bottle feed with formula. Bottle-fed infants are usually given nothing by mouth for the first few 7589_Ch06_069-096 29/08/17 12:03 PM Page 86 86 Journey Across the Life Span hours of life. The first feeding begins with glucose and water; if this is tolerated, the infant progresses to the formula of choice. Bottle-fed newborns require a feeding every 3 to 4 hours at first and then according to their individual hunger patterns. The caregiver should never prop the bottle and leave the infant unattended. The baby should never be allowed to sleep with a bottle that contains anything other than water. Putting juice or milk in a nighttime bottle can lead to bottle-mouth syndrome, which is dental caries caused by sugar in the milk or juice that weakens the tooth surfaces. By 8 or 9 months, infants are ready to be weaned—that is, they can accept the cup in place of the bottle or breast. Weaning and Introduction of Solid Foods Weaning should be done gradually, one feeding at a time. The noon bottle is usually a good feeding to eliminate first; the baby isn’t too tired or hungry to attempt learning to use the cup. In addition to breast milk or formula, many pediatricians recommend the introduction of solid foods after the fifth month. Adding food to the baby’s diet earlier is believed to add to digestive problems and possible food intolerances. One dietary concern after 5 months is that the infant’s stored iron reserve is reduced. For this reason, ironrich foods such as cereals, vegetables, and meats should be added to the diet. A daily supply of vitamin C helps to enhance the body’s absorption of iron. The first solid food introduced into the infant’s diet is usually rice cereal mixed with formula. It is recommended that only single-grain cereals be used at first and that egg whites, wheat, and citrus fruits not be used in the first year. These foods have been known to cause allergic reactions in many infants. It is best to introduce only one new food at a time for several days to detect any adverse reactions. A general rule is to add 1 to 2 teaspoons of each new food, gradually increasing the amount to 1 tablespoon of each food item for each year. The 1-year-old baby eats three meals per day. Table 6.5 shows a schedule of foods for the first year of life. Box 6.2 shows a sample menu for the 10- to 12-month-old child. SLEEP AND REST The neonate sleeps a great deal, as much as 20 out of 24 hours. The faster the rate of growth, the more sleep is required. By 1 year of age, the baby will H E L P F U L H I N T S An approach to managing adverse food reactions includes the following steps: 1. Alter the diet to eliminate symptoms without compromising nutrition. 2. Slowly reintroduce a food to see if symptoms recur; if so, remove the food for 1 to 3 months. 3. Discuss with the physician if symptoms persist. 4. Alert family members and other possible caregivers. need only about 12 hours of sleep a day. The newborn’s sleep pattern is not continuous but is characterized by periods of light sleep marked by stirring movements and noises (Fig. 6.16). Sleep patterns may be interrupted by discomfort and hunger. A bedtime routine will help to establish a nighttime sleeping pattern. This consistent approach to bedtime helps to reduce anxiety and make the infant feel more secure. Early on, help infants learn to distinguish day from night by interacting during the day hours and by keeping talking, cuddling, and interactions to a minimum at night. Infants should be placed awake in their cribs so that they learn to soothe themselves and fall asleep on their own. During the first year most infants require both a morning and an afternoon nap to replenish their stamina. Table 6.6 summarizes the newborn’s sleep patterns. Sudden infant death syndrome (SIDS) is responsible for the death of about 1 out of every 500 babies, most commonly between the ages of 1 and 4 months. Although the exact cause of SIDS (also known as “crib death”) is still unknown, recent research indicates an association between SIDS and sleep patterns. Death usually occurs between midnight and 6 a.m. The American Academy of Pediatrics recommends as a preventative measure that healthy infants sleep on their backs and sides and not on their stomachs. It also has been suggested that parents should offer a pacifier to infants to reduce the risk of SIDS. Studies have suggested that infants who sucked a pacifier during sleep were at less risk of developing SIDS. In addition, infants should be put to sleep in cribs that meet current safety standards. Parents should not use soft materials such as quilts, comforters, or pillows in the sleeping area. Co-sleeping arrangements in the parents’ bed may pose the danger of suffocation or entrapment for the infant. In these cases special care must be taken to avoid placing the bed against a wall 7589_Ch06_069-096 29/08/17 12:03 PM Page 87 Prenatal Period to 1 Year 87 T A B L E 6.5 Sc h ed u l e of F ood s , B i r t h t o 12 M o nths Age Food Selections Rationale Birth–6 months Give only breast milk or iron-fortified formula. Sucking and rooting reflexes allow infants to take in milk and formula; infants cannot accept semisolids because their tongues protrude when a spoon is put into their mouths. Add water. Small amounts may be offered in hot weather or if the infant has diarrhea. Add iron-fortified instant cereal; begin with rice cereal; avoid wheat cereal for first year. Infants are now able to swallow semisolid food; cereal adds iron and vitamins A, B, and E. Add plain, unsweetened fruit juices, fortified with vitamin C; dilute with equal parts water. Fruit juices provide vitamin C. Add plain, strained fruits and vegetables; plain yogurt; strained meats; avoid combinations. Fruits and vegetables introduce new flavors and textures; meats provide iron, protein, and B vitamins. Add zwieback, toast, crackers. They provide iron, protein, and B vitamins. Continue with iron-fortified formula, infant cereal, and fruit juices. Infants still need iron because they are not yet consuming large amounts of meat; this prepares the infant for weaning from bottle or breast. 9–10 months Add finger foods: cooked, bite-sized pieces of meat; vegetables, soft fresh or canned; unsweetened fruits; yogurt; cottage cheese; continue with ironfortified formula, infant cereal, and fruit juices. These encourage self-feeding for motor skill development, and they introduce ne