Nursing Care of Infants (0-1 Year) PDF

29 Nursing Care of a Family With an Infant KEY TERMS baby-bottle syndrome binocular vision deciduous teeth eighth-month anxiety extrusion reflex hand regard natal teeth neck-righting reflex neonatal teeth object permanence pincer gra...

29 Nursing Care of a Family With an Infant KEY TERMS baby-bottle syndrome binocular vision deciduous teeth eighth-month anxiety extrusion reflex hand regard natal teeth neck-righting reflex neonatal teeth object permanence pincer grasp seborrhea social smile thumb opposition OBJECTIVES After mastering the contents of this chapter, you should be able to: 1. Identify Healthy People 2030 goals related to high-risk newborns that nurses could help the nation achieve. 2. Formulate nursing diagnoses related to infant growth and development and associated parent/caregiver concerns. 3. Identify expected outcomes to promote optimal infant growth and developmental needs as well as manage seamless transitions across differing healthcare settings. 4. Evaluate expected outcomes for achievement and effectiveness of care. 5. Describe typical infant growth and development and associated parental concerns. 6. Assess an infant for typical growth and development milestones. 7. Using the nursing process, plan nursing care that includes the six competencies of Quality and Safety Education for Nurses (QSEN): patient-centered care, teamwork and collaboration, evidence-based practice (EBP), quality improvement (QI), safety, and informatics. 8. Implement nursing care related to typical growth and development of an infant, such as encouraging eye–hand coordination. 9. Integrate knowledge of infant growth and development with the interplay of the nursing process, the six competencies of QSEN, and family nursing to promote quality maternal and child health nursing care.  A 19-year-old parent and infant arrive at the pediatric clinic for the infant’s 2-month-old well visit. The parent looks tired and tells the nurse the baby “cries every evening for hours,” and it is exhausting. The parent stopped breastfeeding, changed to formula, and then started rice cereal to see if that would help. It did not help. The parent reports stools are daily and soft. Length, weight, and head circumference remain at the previous percentiles. The infant displays a social smile. The previous chapters described the newborn, newborn feeding, and the high-risk newborn. This chapter provides information about the dramatic changes, both physical and psychosocial, that occur during the first year. What common condition in early infancy might the parent be describing? What factors might be playing a role? What suggestions could support the parent in caring for the infant? Traditionally, infancy includes ages 1 month to 1 year. From birth to 1 month is termed the newborn period. In these important months, an infant undergoes such rapid development that parents sometimes believe their baby looks different and demonstrates new abilities every day. With the process of attachment to a primary caregiver, the infant forms a first social relationship. Due to the growth and learning potential that occurs, this first year is a crucial one. Without proper nutrition, a baby will not grow and physically thrive; without proper stimulation and nurturing care by a consistent caregiver, an infant may not develop a healthy attachment relationship or a feeling of security that is essential for future healthy emotional and social development (Goldson et al., 2020). Box 29.1 highlights Healthy People 2030 goals addressing this important developmental stage. BOX 29.1 Nursing Care Planning Based on 2030 National Health Goals A number of Healthy People 2030 goals focus on the promotion of health during the infant year. These include: Increase the proportion of infants who are breastfed at 1 year from a baseline of 35.5% to a target of 54.1%. Reduce the rate of infant deaths related to congenital anomalies (congenital heart defects). Baseline 0.38 infant deaths per 1,000 live births attributed to congenital heart and vascular defects. Target 0.34 infant deaths per 1,000 live births. Increase the number of states where a child fatality team reviews sudden and unexpected deaths in infants. Reduce the rate of infant deaths from a baseline of 5.8 out of 1,000 live births to a target of 5.0 out of 1,000 live births. Increase the proportion of infants who are put to sleep on their backs from a baseline of 78.7% to a target of 88.9%. Nurses can help the nation achieve these goals by educating parents about the importance of continuing exclusive breastfeeding for 6 months and following proper safety precautions, including using infant car seats, childproofing the home, and instigating measures to prevent SIDS such as placing infants to sleep on their backs. U.S. Department of Health and Human Services. (2020). Healthy People 2030. Author. Nursing Process Overview ASSESSMENT Nursing assessment of an infant begins with an interview with the primary caregiver. Important areas to discuss include nutrition, elimination, growth patterns, and development. An infant’s weight, length, and head circumference are important indicators of growth, so they should be measured and plotted on standardized growth charts. Growth charts, which plot growth patterns, are available from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Typical infant appearance is shown in Box 29.2. The physical assessment of an infant must be done efficiently because a baby gets fussy if there is excessive stimulation. Observe behavior and temperament prior to the examination. It is best if a caregiver is present, to make the infant feel secure. Performing the assessment provides the opportunity to provide education of any common findings or developmental milestones that are observed. A general appearance can be obtained while the infant is being held by the parent/caregiver. If the infant is initially quiet, assess the respiratory and cardiac system first. BOX 29.2 Nursing Care Planning Using Assessment APPEARANCE OF THE AVERAGE INFANT NURSING DIAGNOSIS Much of the assessment of an infant and family will focus on basic needs such as sleep, nutrition, and activity and the caregivers’ adjustment to their new role. Examples of nursing diagnoses include: Ineffective breastfeeding related to sore nipples Sleep deprivation (parental) related to providing infant’s care Knowledge deficiency related to typical infant growth and development Malnutrition risk, less than body requirements, related to infant’s difficulty sucking Health-seeking behaviors related to adjusting to parenthood Growth and development delays related to lack of stimulating environment Impaired parenting risk related to recent hospitalization of infant Readiness for enhanced family coping related to increased financial support Social isolation (parental) related to lack of adequate social support Ineffective role performance related to new responsibilities within the family OUTCOME IDENTIFICATION AND PLANNING Outcomes established for infant care need to be realistic based on the family’s individual circumstances. Parents/caregivers of infants, especially first-time parents, require education and anticipatory guidance. Suggest activities that are individualized based on the family’s lifestyle and personal preferences. For example, if assessment data (flattened occipital area on the infant’s head) indicate that the infant needs more time on its abdomen (tummy time), demonstrate to parents how to perform this activity so the infant accepts it and it is done safely. Working together, these actions should permit the head to return to its shape. Parents/caregivers might find online referred resources helpful. Further information regarding online resources may be found in Chapter 28. IMPLEMENTATION One of the most important interventions of the infant period is teaching parents about typical growth and development milestones, such as the expected age range for rolling over or reaching for objects. Whenever possible, this information should be anticipatory, so parents can anticipate this new skill and are prepared for changes in development before they occur. This enables parents to focus on safety to prevent the infant from rolling off a surface or reaching for an object that could cause injury. OUTCOME EVALUATION Evaluate expected outcomes at each visit to document progress in physical growth and development. Help parents/caregivers understand progress in the development regarding the areas of social, language, and fine motor and gross motor skills. There is a range of expected achievement of developmental milestones and an identified age when there is a delay in reaching those milestones. If there is a delay in one of the four areas, further evaluation is required. It is important to consider relevant prenatal and natal history that may affect reaching developmental milestones. Prematurity is an example of relevant natal history. For every week a newborn is born prior to 37 weeks gestation, achievement of developmental milestones may be delayed by a week without concern. Examples of expected outcomes include: Parent/caregiver acknowledges feeling fatigued but able to cope with sleep disturbance from night waking. Parents/caregivers state five actions they are taking daily to encourage bonding. Parents/caregivers state they are adjusting to new role as parents. Parents/caregivers verbalize appropriate techniques they use to stimulate infant. Infant demonstrates age-appropriate growth and development. Infant’s weight, length, and head circumference are progressing following previously established percentiles on the growth chart. Growth and Development of an Infant Infants grow rapidly both in size and in their ability to perform tasks during their first year. A standard schedule for healthcare visits is for 2-week, 2-month, 4-month, 6-month, 9-month, and 12-month visits (American Academy of Pediatrics [AAP], 2017). These visits are important for the infant because they provide the opportunity to provide immunizations, obtain growth measurements, and perform health assessments; they are important for caregivers because they provide an opportunity to ask questions about their child’s growth pattern and developmental progress. They provide opportunities for healthcare providers to assess for potential problems when they first appear. Anticipatory guidance offered at these visits can help caregivers prepare for the rapid changes that occur during the first year of life. When appropriate, encouraging parents/caregivers to participate in infant/caregiver networking groups is another way to help increase their knowledge base and confidence level to care for their rapidly growing infant. There are many apps caregivers can use to document their child’s growth, feeding, sleep, elimination, and development milestones (https://www.babyconnect.com/). Many online resources provide guidance on expected developmental milestones and include an app to record milestones (https://www.cdc.gov/ncbddd/actearly/milestones-app.html). This is a free app for children 2 months to 5 years and includes a milestone checklist specific to the child’s birthdate. Sections include when to act, tips and activities, milestones, and a child summary. The entries can be shared with a healthcare provider. Table 29.1 details the usual procedures done at infant health maintenance visits. The vaccines administered during the first year are discussed in Chapter 34. TABLE 29.1 HEALTH MAINTENANCE SCHEDULE, INFANT PERIOD Physical Health Physical Examination Frequency Developmental milestones History, observation Every visit including psychosocial interaction Ages and Stages Questionnaire At 9 months Growth milestones Height, weight, head circumference plotted on standard growth Every visit chart; physical examination Vision and hearing History, observation Every visit Physical examination Every visit Nutritional adequacy History, observation Every visit Parent–child relationship History, observation Every visit Sleep positioning Discussion of placing infants on back to sleep; using “tummy time” Every visit up to 9 months counseling for play periods during the day Unintentional injury Discussion of safety measures to take with infants Every visit counseling Dental health History, physical examination Every visit after teeth erupt Fluoride varnish Recommended every visit starting at 6 months with tooth eruption Anemia Hematocrit, hemoglobin 12-month visit Lead screening Point of Care rapid lead screening 12-month visit Tuberculosis screening Purified protein derivative (PPD) test (if warranted) If indicated based on risk Newborn screening Heel blood sample At 2-week visit Immunizations Review of history and health record; teaching parent about any risks and side effects; administering immunization in accordance with healthcare agency policies Haemophilus influenzae Hib 2-, 4-, 6-, and 12-month Type B visits Varicella VAR 12-month visit Inactivated poliomyelitis IPV 2-, 4-, and 6-month visits virus Pneumococcal disease PCV 2-, 4-, 6-, and 12-month visits Diphtheria, tetanus and DTaP 2-, 4-, 6-, and 12–15 pertussis (whooping months cough) Hepatitis B HepB Birth, 2-month, and 6- or 12-month visits Rotavirus RV 2-, 4-, and possibly at 6- month visit depending on manufacturer Influenza IIV Yearly at 6-month or later visit Mumps, measles, and MMR 12- or 15-month visit rubella Varicella Var 12- or 15-month visit Hepatitis A HepA 12- or 15-month visit Anticipatory Guidance Infant care Active listening and health teaching Every visit Expected growth and Health teaching Every visit  developmental milestones before next visit Poison and unintentional Educate caregivers about infant safety, such as using car seats and Every visit injury prevention locking up poisons; provide telephone number of national poison control center (800-122-1222) Problem Solving Any problems expressed Active listening and health teaching regarding nutrition, exercise, Every visit by parent during course language development of the visit PCV, pneumococcal conjugate vaccine. Data from American Academy of Pediatrics. (2021). 2021 Periodicity schedule: Recommendations for preventive pediatric health care. https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf PHYSICAL GROWTH The physiologic changes that occur in the infant year reflect both the increasing maturity and growth of body organs. Weight In general, infants double their birth weight by 4 to 6 months and triple it by 1 year. During the first 6 months, infants typically average a weight gain of 2 lb per month. During the second 6 months, weight gain is approximately 1 lb per month. The average 1-year-old male weighs 10 kg (22 lb); the average 1-year-old female weighs 9.5 kg (21 lb). An infant’s weight, however, is relevant only when plotted on a standard growth chart and compared to that child’s own growth curve. Length An infant increases in length during the first year by 50%, or grows from the average birth length of 20 in. to about 30 in. (50.8 to 76.2 cm). Length, like weight, is assessed best if it is plotted on a standard growth chart. Infant growth is most apparent in the trunk during the early months. During the second half of the first year, it becomes more apparent as lengthening of the legs occurs. At the end of the first year, the child’s legs may still appear disproportionately short, however, and perhaps bowed. For accuracy, measure infants lying supine on a measuring board even if they are beginning to be able to stand (see Chapter 34, Box 34.9). Head Circumference By the end of the first year, the brain already reaches two-thirds of its adult size. Head circumference increases rapidly during the infant period to reflect this rapid brain growth. Some infants’ heads appear asymmetric until the second half of the first year, especially if they are always placed on their back to sleep (as recommended), causing the skull bones to flatten in the back. Suggest to parents/caregivers they continue to place the infant on their back for sleep but to spend “tummy time” daily with the infant placed in a prone position to prevent this flattening. This early head distortion will gradually correct itself as the child sleeps less and spends more time with the head in an erect position. Persistence of asymmetry suggests an infant is not receiving enough stimulation. Body Proportion Body proportion changes during the first year from that of a newborn to a more typical infant appearance. By the end of the infant period, the lower jaw is definitely prominent and remains that way throughout life. The circumference of the chest is generally less than that of the head at birth by about 2 cm. It is even with the head circumference in some infants as early as 6 months and in most by 12 months. Chest circumference is typically not measured at each visit. The abdomen remains protuberant until the child has been walking well into the toddler period. Cervical, thoracic, and lumbar vertebral curves develop as infants hold up their head, sit, and walk. Lengthening of the lower extremities during the last 6 months of infancy readies the child for walking and often is the final growth that changes the appearance from “baby-like” to “toddler-like.” Body Systems In the cardiovascular system, heart rate slows from 110 to 160 beats per minute to 100 to 120 beats per minute by the end of the first year. The heart continues to occupy a little over half the width of the chest. Pulse rate may slow with inhalation (sinus arrhythmia), but this does not become marked until preschool age. That the heart is becoming more efficient is shown by a decreasing pulse rate and a slightly elevated blood pressure (from an average of 80/40 to 100/60 mm Hg). Infants are prone to develop a physiologic anemia at 2 to 3 months of age. This occurs because the life of a typical red cell is 4 months, so the cells the child had at birth begin to disintegrate at that time, yet new cells are not being produced in adequate replacement numbers. Hemoglobin in an infant becomes totally converted from fetal to adult hemoglobin at 5 to 6 months of age. Infants may experience a decrease in serum iron levels at 6 to 9 months as the remaining iron stores established in utero are used. The respiratory rate of an infant slows from 30 to 60 breaths per minute to 20 to 30 breaths per minute by the end of the first year. Because the lumens of the respiratory tract remain small and mucus production by the tract to clear invading microorganisms is still inefficient, upper respiratory infections occur more often and tend to be more severe than in adults. This is dependent on the time of year (more prevalent in the winter months) and the extent of exposure (infant in childcare). At birth, the gastrointestinal tract is immature in its ability to digest food and mechanically move it along. These functions mature gradually during the infant year. Although the ability to digest protein is present and effective at birth, the amount of amylase, which is necessary for the digestion of complex carbohydrates, is deficient until approximately the third month. Lipase, necessary for the digestion of saturated fat, is decreased in amount during the entire first year. The liver of an infant remains immature, possibly causing an inadequate conjugation of drugs (if a drug should be necessary for treatment of illness) and the inefficient formation of carbohydrate, protein, and vitamins for storage. Until age 3 or 4 months, an extrusion reflex (food placed on an infant’s tongue is thrust forward and out of the mouth) prevents some infants from eating effectively if they are offered solid food this early (not recommended). Newborns can drink from a cup as long as a parent controls the fluid flow. An infant can independently drink from a cup by age 8 or 10 months. The kidneys remain immature and not as efficient at eliminating body wastes as in an adult. The endocrine system remains particularly immature in response to pituitary stimulation, such as adrenocorticotropic hormone, or insulin production from the pancreas. Without these hormones functioning effectively, an infant may not be able to respond to stress as effectively as an adult may. An infant’s immune system becomes functional by at least 2 months of age; an infant can actively produce both immunoglobulin (Ig)G and IgM antibodies by 1 year. The levels of other Igs (IgA, IgE, and IgD) are not plentiful until preschool age, which is the reason why infants continue to need protection from infection (Goldson et al., 2020). The ability to adjust to cold is mature by age 6 months. By this age, an infant can shiver in response to cold (which increases muscle activity and provides warmth) and has developed additional adipose tissue to serve as insulation. The amount of brown fat, which protected the newborn from cold, decreases during the first year as subcutaneous fat increases. Although the fluid in body compartments shifts to some extent, extracellular fluid accounts for approximately 35% of an infant’s body weight, with intracellular fluid accounting for approximately 40% by the end of the first year, in contrast to adult proportions of 20% and 40%, respectively. This proportional difference increases an infant’s susceptibility to dehydration from illnesses, such as diarrhea, because loss of extracellular fluid could result in loss of over a third of an infant’s body fluid. Teeth The first baby tooth (typically, a central incisor) usually erupts at age 6 months, followed by a new tooth monthly until all 20 deciduous (baby) teeth have erupted by age 2 to 3 years. Fluoride supplementation should be administered at 6 months of age (AAP, 2015c). However, teething patterns can vary greatly among children. Figure 29.1 illustrates the usual ages of deciduous eruption by tooth type. Figure 29.1 A typical eruption pattern of deciduous teeth. Some newborns (about one in 2,000) may be born with teeth (natal teeth) or have teeth erupt in the first 4 weeks of life (neonatal teeth). The lower central incisors (see Fig. 29.1) are the teeth most frequently involved in this early growth. These very early teeth may be membranous and may be reabsorbed (supernumerary or extra teeth). If they are loosely attached, they are usually removed before they loosen spontaneously and are aspirated by the infant. In most infants, natal or neonatal teeth are deciduous or are fixed firmly. These should not be removed because no other teeth will grow to replace them until the permanent teeth erupt at age 6 or 7 years. Deciduous teeth are essential for allowing proper growth of the dental arch. If they are injured, children need a dental evaluation to be certain there is space for permanent teeth to erupt effectively or that permanent teeth are not discolored (Hagan et al., 2017). MOTOR DEVELOPMENT An average infant progresses through systematic motor growth during the first year, strongly reflecting the principles of cephalocaudal (head to toe) and gross-to-fine motor development. Control proceeds from head to trunk to lower extremities in a progressive, predictable sequence. As different infants show individual variations in accomplishing different tasks, the ages given here are only averages. To assess motor development, both gross motor development (ability to accomplish large body movements) and fine motor development, measured by observing or testing prehensile ability (ability to coordinate hand movements), are evaluated. Gross Motor Development Four positions—ventral suspension, prone, sitting, and standing—are used to assess gross motor development. Ventral Suspension Position Ventral suspension refers to an infant’s appearance when held in midair on a horizontal plane and supported by a hand under the abdomen (Fig. 29.2A). In this position, the newborn allows the head to hang down with little effort at control. One-month-old infants lift their head momentarily and then drop it again. Two-month-old infants hold their head in the same plane as the rest of their body, a major advance in muscle control. By 3 months, infants lift and maintain their head well above the plane of the rest of the body in ventral suspension. Figure 29.2 A. The ventral suspension position. B. The prone position. A Landau reflex is a new reflex that develops at 3 months. When held in ventral suspension, the infant’s head, legs, and spine extend. When the head is depressed, the hips, knees, and elbows flex. This reflex continues to be present in most infants during the second 6 months of life, but then it becomes increasingly difficult to demonstrate. It is an important reflex to assess because a child with motor weakness, cerebral palsy, or other neuromuscular defects will not be able to demonstrate the reflex. At 6 to 9 months, an infant also demonstrates a parachute reaction from a ventral suspension position. This means that when infants are suddenly lowered toward an examining table, the arms extend as if to protect themselves from falling. Children with cerebral palsy do not demonstrate this response because they flex their extremities too tightly. Prone Position When lying on their stomach, newborns can turn their head to move it out of a position where breathing is impaired, but they cannot hold their head raised for an extended time (see Fig. 29.2B). By 1 month of age, they lift their head and turn it easily to the side. They still tend to keep their knees tucked under their abdomen, however, as they did as a newborn. Two-month- old infants can raise their head and maintain the position, but they cannot raise their chest high enough to look around yet. Their head is still held facing downward. A 3-month-old child lifts the head and shoulders well off the table and looks around when prone. The pelvis is flat on the table, no longer elevated. Some children can turn from a prone to a side-lying position at this age. Four-month-old infants lift their chests off the bed and look around actively, turning their head from side to side. They are able to turn from front to back. The first time, this tends to occur as an extension of lifting the chest combined with a neck-righting reflex, which begins at this age. This reflex causes babies to lose their balance and roll sideways when lifting the head up. The baby is frightened by the sudden feeling of rolling free and probably cries. After this happens a few more times, however, a baby begins to delight in this new accomplishment. Most babies turn front to back first and then, 1 month later, back to front. When taking a health history, ask which way a child turned first. Those with spasticity may turn first back to front. This is not necessarily an indication of spasticity because some healthy babies turn back to front first. Five-month-old infants are able to rest weight on their forearms when prone. They can turn completely over, front to back and back to front. By 6 months, infants can raise their chests and the upper part of their abdomens off the table. By 9 months, a child can creep from the prone position. Creeping means the child has the abdomen off the floor and moves one hand and one leg and then the other hand and leg, using the knees on the floor to move (Fig. 29.3). Figure 29.3 Creeping. When infants creep, they move forward with one arm and leg and then the other arm and leg, carrying the torso above and parallel to the floor. (leungchopan/Shutterstock.com) Sitting Position When the infant is placed on the back and then pulled to a sitting position, a newborn has extreme head lag; this lag is present until about 1 month (Fig. 29.4). In a sitting position, the back appears rounded and an infant demonstrates only momentary head control. Figure 29.4 An infant is pulled to a sitting position to demonstrate head lag. Notice how evident this is in the young infant. By 2 months, infants can hold their head steady when sitting up, although their head does tend to bob forward and will still show head lag when pulled to a sitting position. A 4-month-old child reaches an important milestone by no longer demonstrating head lag when pulled to a sitting position. A 5-month-old infant can be seen to straighten their back when held or propped in a sitting position. By 6 months, infants can sit momentarily without support. They anticipate being picked up and reach up with their hands from this position. Some parents/caregivers expect a child this age to be able to sit securely and may be worried because their sitting posture is still extremely shaky; however, this is common (Fig. 29.5). Infants are capable of movement by sliding backward from this position. Inform parents/caregivers that an infant this young is capable of moving from one spot to another in this way so that they are prepared for this and can prevent unintentional injuries. Figure 29.5 A 6-month-old infant not quite ready to sit on their own. Notice how the infant is propped with pillows to maintain the position. A 7-month-old child can sit alone but only when the hands are held forward for balance. An 8-month-old child can sit securely without any additional support (Fig. 29.6). This is a major milestone in development that should always be considered in an assessment. Children with delayed cognitive or motor development may not accomplish this step at this time. At 9 months, infants sit so steadily that they can lean forward and regain their balance. They may still lose their balance if they lean sideways, which is a skill not achieved for another month. Figure 29.6 At 8 months of age, an infant sits independently. Standing Position A newborn stepping reflex can still be demonstrated at 1 month of age. In a standing position, the infant’s knees and hips flex rather than support more than momentary weight. At 3 months, infants try to support part of their weight on their feet. At 4 months, infants are able to support their weight on their legs. They are successful at doing this because the stepping reflex has faded. By 5 months, the tonic neck reflex should be extinguished, and the Moro reflex should be fading. By 6 months, infants nearly support their full weight when in a standing position. A 7-month- old child bounces with enjoyment in a standing position. Nine-month-olds can stand holding onto a low table if they are placed in that position. Ten-month-olds can pull themselves to a standing position by holding onto the side of a playpen or a low table, but they cannot let themselves down again. At around 11 months, an infant learns to “cruise” or move about the crib or room by holding onto objects such as the crib rails, chairs, walls, and low tables (Fig. 29.7). At 12 months, the child can stand alone at least momentarily. Some parents/caregivers expect children to walk at this time and may be disappointed to see their child is merely standing still. A child has until about 22 months of age to walk and still be within the expected time frame (Fig. 29.8). Figure 29.8 There is a wide variation in the age at which children take a first step, typically ranging from 8 to 15 months. Here, a child has mastered walking. Figure 29.7 An 11-month-old child cruising along the walls. Further childproofing of the house will be necessary to keep the child safe. (Photo Researchers, Inc.) QSEN Checkpoint Question 29.1 TEAMWORK AND COLLABORATION The nurse is collaborating with the occupational therapist on 2-month-old care. When planning care, the nurse identifies the infant should sit unsupported at what age? a. 2.5 months b. 6 months c. 8 months d. 12 months Look in Appendix A for the best answer and rationale. Fine Motor Development One-month-old infants still have a strong grasp reflex, so they hold their hands in fists so tightly that it is difficult to extend their fingers. As the grasp reflex fades, a 2-month-old infant will hold an object for a few minutes before dropping it. The hands are held open, not closed in fists. By 3 months, infants reach for attractive objects in front of them. Their grasp is unpracticed so they usually miss them. You can assure parents/caregivers this is a typical part of development so they do not think their child is nearsighted or farsighted or has poor coordination. When they reach 4 months, infants bring their hands together and pull at their clothes. They will shake a rattle placed in their hand. Thumb opposition (ability to bring the thumb and fingers together) begins, but the motion is a scooping or raking one, not a picking-up one, and is not very accurate. This limits the infant to handling large objects (Fig. 29.9). Palmar and plantar grasp reflexes have disappeared. Figure 29.9 By age 4 months, an infant is able to manipulate large objects. Five-month-old children can accept objects that are handed to them by grasping with the whole hand. They can reach and pick up objects without the object being offered and often play with their toes as objects. Fisting that persists beyond 5 months suggests a delay in motor development. Unilateral fisting suggests hemiparesis or paralysis on that side. By 6 months, grasping has advanced to a point where a child can hold objects in both hands. Infants at this age will drop one toy when a second one is offered. They can hold a spoon and start to feed themselves (with much spilling). The Moro, the palmar grasp, and the tonic neck reflexes have completely faded. A Moro reflex that persists beyond this point should arouse suspicion of neurologic disease. Seven-month-old infants can transfer toys from one hand to the other. They hold a first object when a second one is offered. By 8 months, random reaching and ineffective grasping disappear as a result of advanced eye–hand coordination. A major milestone at 10 months is the ability to bring the thumb and first finger together in a pincer grasp (Fig. 29.10). This enables children to pick up small objects such as crumbs or pieces of cereal from a high chair tray. They use one finger to point to objects. They offer toys to people but then cannot release them. Figure 29.10 An infant almost ready to demonstrate a pincer grasp. At 12 months, infants can hold a crayon well enough to draw a semi-straight line. They enjoy putting objects such as small blocks in containers and taking them out again. They can hold a cup and spoon to feed themselves fairly well (if they have been allowed to practice) and can take off socks and push their hands into sleeves (again, if they have been allowed to practice). They can offer toys and release them. DEVELOPMENTAL MILESTONES In addition to the gross and fine motor skills developing at this time, language and play behavior also reach major milestones. For easy reference, motor and cognitive development and play throughout this year are summarized in Table 29.2. TABLE 29.2 SUMMARY OF INFANT GROWTH AND DEVELOPMENTAL MILESTONES Socialization Time Fine Motor and Reflexes Month Motor Development Development Language Fade Play 0–1 Largely reflex actions Keeps hands fisted; — — Enjoys watching face of primary able to follow caregiver; needs play time in object to midline prone position with eyes 2 Holds head up when Demonstrates social Makes cooing Grasp reflex Enjoys bright-colored mobiles prone smile sounds; fading differentiates cry 3 Holds head and chest Follows object past Laughs out Landau reflex Spends time looking at hands up when prone midline with eyes loud is strong. (hand regard); “tummy time” important during the day 4 Turns back to front; no — — Stepping, tonic Needs space to practice turning longer has head lag; neck, bears partial weight extrusion on feet reflexes are fading. 5 Should turn readily Tonic neck Handles rattles well front to back and reflex fading back to front 6 Begins to show ability Uses palmar grasp May say vowel Moro and tonic Enjoys bathtub toys, rubber ring to sit sounds (oh- neck reflex for teething oh) have faded. 7 Reaches out to be Transfers objects Shows — Likes objects that are good size picked up; first tooth hand to hand beginning for transferring (central incisor) fear of erupts strangers 8 Sits securely without — Fear of — Enjoys manipulation, rattles, and support strangers toys of different textures peaks 9 Creeps or crawls — Says first word — Needs safe space for creeping (abdomen off floor) 10 Pulls self to standing Uses pincer grasp — Plays games like patty-cake and (thumb and finger) peek-a-boo to pick up small objects 11 Cruises (walks with — — — Cruising can be main activity. support) 12 Stands alone; some Holds cup and spoon Says four Landau reflex Likes toys that fit inside each infants take first well; helps to words fades. other (pots and pans); nursery step. dress (pushes arm rhymes; will like pull toys as into sleeve) soon as walking Language Development Language develops step by step, the same as motor development. Infants begin to make small, cooing sounds by the end of the first month. By 2 months, they can differentiate their cry. For example, parents/caregivers can begin to distinguish a cry that means “hungry” from one that means “wet” or one that means “lonely.” This is an important milestone in development for an infant (Hagan et al., 2017). A first-time caregiver usually has more difficulty making the distinction in crying than one who has experienced this before. In response to a nodding, smiling face or a friendly tone of voice, a 3-month-old infant will squeal with pleasure or laugh aloud. The same as with differentiating a cry, this is an important step in development because it makes a baby even more fun to be with and increases socialization. Caregivers spend increased time with infants at this age, not just to care for them but because they enjoy watching them smile at attention. By 4 months, infants are very talkative, and when spoken to, they start cooing, babbling, and gurgling. They definitely laugh aloud. By 5 months, an infant says some simple vowel sounds (e.g., “goo-goo,” “gah-gah”). At 6 months, infants learn the art of imitating. They may imitate a parent’s cough, for example, or say “Oh!” as a way of attracting attention. The amount of talking infants do increases still more at 7 months. They can imitate vowel sounds well (e.g., “oh-oh,” “ah-ah,” “oo-oo”). By 9 months, an infant usually speaks a first word: “da-da” or “ba-ba.” By 10 months, an infant masters another word such as “bye-bye” or “no.” By 12 months, infants can generally say an additional two words, and they use those two words with meaning. QSEN Checkpoint Question 29.2 INFORMATICS Beginning verbal communication is one of the most important tasks that infants need to achieve. The nurse teaches parents that by 12 months of age the child can be expected to display which characteristics? a. “Children this age can usually say around four words.” b. “One-year-olds can usually say more words than they are able to understand.” c. “A 12-month-old child can express basic needs verbally.” d. “An infant who is this age usually can’t understand spoken words.” Look in Appendix A for the best answer and rationale. Play Caregivers often ask what toys their infant would enjoy. Because 1-month-olds can fix their eyes on an object, they are interested in watching a mobile over their crib or playpen. Mobiles are best if they are black and white or brightly colored and light enough in weight so they move when someone walks by. Mobiles should face down toward the infant, not toward the adult standing beside the crib. Musical mobiles provide extra stimulation. One-month-old children also spend a great deal of time watching their caregivers’ faces, appearing to enjoy this activity so much that a face may become their favorite toy. Hearing is a second sense that is a source of pleasure for children in early infancy. Even newborns listen to the sound of a music box or a musical rattle. They stir and seem apprehensive at the sound of a raucous rattle. Two-month-old infants will hold light, small rattles for a short period but then drop them. They are attuned to mobiles or cradle gyms strung across their crib. They continue to spend a great deal of time just watching the people around them. Three-month-old infants can handle small blocks or small rattles. Four-month-olds need a playpen or a sheet spread on the floor so they have an opportunity to exercise their new skill of rolling over. Rolling over may be so intriguing that it can serve as a toy for the entire month. Five-month-old infants are ready for a variety of objects to handle, such as plastic rings, blocks, squeeze toys, clothespins, rattles, and plastic keys. Check that all of these are small enough that an infant can lift them with one hand, yet big enough that they cannot possibly swallow them. A 6-month-old child can sit steadily enough to be ready for bathtub toys such as rubber ducks or plastic boats if carefully supervised. Because they are starting to teethe, most at this age enjoy a teething ring to chew on. Because 7-month-old infants can transfer toys, they are interested in items such as blocks, rattles, or plastic keys that are small enough to be transferred easily. As their mobility increases, they begin to be more interested in brightly colored balls or toys that previously rolled out of reach. Eight-month-old infants are sensitive to differences in texture. They enjoy having toys with different feels to them, such as velvet, fur, and fuzzy, smooth, or rough items. The 9-month-old infant needs the experience of creeping. This means time out of a crib or playpen so there is room to maneuver. Many 9-month-olds begin to enjoy toys that go inside one another, such as a nest of blocks or rings of assorted sizes that fit on a center post. Some are more interested in pots and pans that stack rather than toys. By 10 months, infants are ready for peek-a-boo and will spend a long time playing the game with their hands or with a cloth over their head that they can easily reach and remove. They can clap, so they are also ready to play patty-cake. These games have a positive value, just as laughing aloud did for the 3-month-old. They make the baby feel like an active part of the household. A family feeling begins to grow as the baby begins to actively participate in this type of game. By 11 months, children have learned to cruise or walk by holding on to low tables. They often find this so absorbing that they spend little time doing anything else during the month. Twelve-month-old infants enjoy putting things in and taking things out of containers. They like little boxes that fit inside one another or dropping small blocks into a larger box. As soon as they can walk, they will be interested in pull toys. They enjoy listening to someone recite nursery rhymes or play music. Although there is an advantage to television watching for children during the preschool age because it can help them learn language, the AAP recommends that infants not be exposed to television (AAP, 2016). They do not need exposure to the amount of violence seen on TV (including animation for children or children’s programs), and socialization with people is preferred. What If… 29.1 Parent asks the nurse for advice on a good toy for infant at 2 months of age. What does the nurse recommend? DEVELOPMENT OF SENSES Like other facets of development, maturation of the senses proceeds progressively during the infant year. Vision One-month-old infants are able to regard an object in the midline of their vision (something directly in front of them) as soon as it is brought in as close as about 18 in. (46 cm). They follow the object a short distance if it moves, but not across the midline yet. They study or regard a human face with a fixed stare. Two-month-old infants focus well (from about age 6 weeks) and so are able to follow moving objects with the eyes (although still not past the midline). The ability to follow and focus in this way is a major milestone in development, indicating that an infant has achieved binocular vision or the ability to fuse two images into one (Fig. 29.11). Teach parents/caregivers to make a point of initiating eye-to-eye contact with newborns right from birth as a method of stimulating vision as well as a way of promoting socialization. Figure 29.11 A 2-month-old infant focuses steadily and lifts head up while prone. Note the interest in the stuffed bear. Three-month-old infants can follow an object across their midline. They typically hold their hands in front of their face and study their fingers for long periods of time (hand regard). Blind children also demonstrate this phenomenon, so it may not be so much a test of vision as of cognitive or exploratory development. Up until 6 months of age, infants experience some difficulty establishing eye coordination. After 3 months, an infant whose eyes still cross the majority of the time should be examined by a primary care provider to be certain the muscles that control side-to-side vision are not impaired. Four-month-old infants are able to recognize familiar objects, such as a frequently seen bottle, rattle, or toy animal. They eagerly follow their caregivers’ movements with their eyes. By 6 months, infants are capable of organized depth perception. This increases the accuracy of their reach for objects as they begin to perceive distances correctly. Seven-month-olds pat their own image in a mirror. Their depth perception has matured to the extent that they can perform such tasks as transferring toys from hand to hand. By 10 months, an infant looks under a towel or around a corner for a concealed object (the beginning of object permanence, or an awareness that an object out of sight still exists). Most caregivers are aware that infants enjoy mobiles and a crib mirror. Occasionally, caregivers supply so many of these that they can overwhelm the infant with too many patterns and objects dangling above the crib. In a hospital environment, because hospital walls tend to be bland, assess that infants receive adequate visual stimulation (Fig. 29.12). If a child’s movement is restricted in any way, such as by a cast, move the position of a mobile or mirror from time to time to provide a new view. Photos of family members or pictures drawn by older siblings can be posted near the crib. Ask caregivers if there are any items from home that the infant would normally see during the course of the day while being fed, changed, or bathed. Bringing those items into the hospital, if possible, could help visual stimulation. Figure 29.12 A 2-month-old infant enjoys watching a simple mobile. Hearing Hearing can be demonstrated at birth by the way a newborn quiets momentarily at a distinctive sound such as a bell or a squeaky rubber toy. Hearing tests are recommended by 1 month of age by the AAP. By 1 month, this reaction is even more marked. Hearing awareness becomes so acute by 2 months of age that infants will stop an activity at the sound of spoken words. Many 3-month-old infants turn their head to attempt to locate a sound. At 4 months of age, when infants hear a distinctive sound, they turn and look in that direction. By 5 months of age, infants demonstrate they can localize sounds downward and to the side, by turning their head and looking down. Six-month-olds have progressed to being able to locate sounds made above them. By 10 months, infants can recognize their name and when spoken to, listen intently. By 12 months, infants can easily locate sounds in any direction and turn toward them. A vocabulary of four words also demonstrates that an infant can hear. During the first year, infants appear to enjoy soft, musical sounds or cooing voices (Box 29.3); they are startled by harsh or loud sounds. Urge caregivers to choose first toys that make these types of welcoming sounds. Recordings of maternal heart sounds can be soothing to very young infants. For the hospitalized infant, a recording of family voices might be a soothing reminder of their presence. Encourage caregivers to read to their child daily from the beginning of life through the early school-aged years, not only because the sound is comforting but also because this increases language development dramatically (Mendelsohn et al., 2018). BOX 29.3 Nursing Care Planning Tips for Effective Communication A healthcare visit is over for a 2-month-old, and you dress the infant while the parent talks to the healthcare provider. Tip: Role model effective communication with infants to help parents/caregivers learn to incorporate language development as they give care. Infants appreciate someone talking to them even if they do not understand the words. Use language that involves the infant and promotes vocabulary development, such as the naming of colors. Nurse: Are you ready to go home? Look what a cute yellow sweater you have. It matches the yellow duck on your shirt. Ducks say quack, quack, quack when they talk. You look ready. Touch Infants need to be touched so they can experience skin-to-skin contact. Clothes should feel comfortable and soft rather than rough; diapers should be dry rather than wet. Teach caregivers to handle infants with assurance yet gentleness. Taste Infants demonstrate they have an acute sense of taste by turning away from or spitting out a taste they do not enjoy. When infants are introduced to solid food at about 6 months, urge caregivers to make mealtime a time for fostering trust as well as supplying nutrition by being certain that feedings are done at an infant’s pace and the amount offered fits the child’s needs and not the adult’s idea of how much should be eaten. Smell Infants have a highly developed sense of smell within 1 or 2 hours of birth. They respond to an irritating smell by turning their head away from it. They appear to enjoy pleasant odors and learn early in life to identify the familiar smell of breast milk. Teach parents/caregivers to be alert to substances that cause sneezing when sprayed into the air, such as room deodorizers or cleaning compounds, and to keep irritating odors out of their child’s environment. EMOTIONAL DEVELOPMENT Socialization, or learning how to interact with others, is an extensive phenomenon. One-month- old infants show they can differentiate between faces and other objects by studying a face or the picture of a face longer than other objects. They are calm and feed well for the person who has been their primary caregiver. When an interested person nods and smiles at a 6-week-old infant, the infant smiles in return. This is a social smile and is a definite response to the interaction, not the faint, quick smile that younger infants, even newborns, demonstrate. It is a major milestone because it reflects growing maturity in a number of areas, most notably vision, motor control, and intelligence. Children with cognitive differences or children with spasticity may not demonstrate a social smile until much later in the infant year. By 3 months, infants demonstrate increased social awareness by readily smiling at the sight of a caregiver’s face (Fig. 29.13). Three-month-old infants laugh aloud at the sight of a funny face. By 4 months, when a person who has been playing with and entertaining an infant leaves, the infant is likely to cry or show that the interaction was enjoyable. Infants at this age recognize their primary caregiver and prefer that person’s presence to others. By 5 months, infants may show displeasure when an object is taken away from them. This is a step beyond showing displeasure when a person leaves. Figure 29.13 A 3-month-old smiles delightedly at father’s happy face. This indicates increased social awareness. By 6 months, infants are increasingly aware of the difference between people who regularly care for them and strangers. They may begin to draw back from unfamiliar people. Seven-month- old infants begin to show obvious fear of strangers. They may cry when taken from their parent, attempt to cling to the parent, and reach out to be taken back. Parents/caregivers may view this as a bad trait or a regression in socialization. Help them appreciate that it is actually a big step forward because it shows that their infant can differentiate between people and can recognize the difference between persons to trust and others. Fear of strangers reaches its height during the eighth month, so much so that this phenomenon is often termed eighth-month anxiety, or stranger anxiety (Goldson et al., 2020). Remember that an infant at the height of this phase will not go willingly from a parent’s arms to a nurse’s arms. Taking a few minutes to talk to the child and parent first so you are perceived as a friend, not a stranger, is time well spent. Nine-month-old infants are very aware of changes in tone of voice. They cry when scolded, not because they understand what is being said, but because they sense their parent’s displeasure. By 12 months, most children have overcome their fear of strangers and are alert and responsive when approached. They like to play interactive nursery rhymes and rhythm games and “dance” with others. They also like being at the table for meals and joining in family activities. COGNITIVE DEVELOPMENT In the first month of life, an infant mainly uses simple reflex activity. There is little evidence infants at this early age see themselves as separate from their environment. However, this does not mean they cannot respond actively or interact with people. They demonstrate they are very people oriented moments after birth by cuddling against an adult’s chest. Primary and Secondary Circular Reaction By the third month of life, a child enters a cognitive stage identified by Piaget (1952) as primary circular reaction. During this time, the infant explores objects by grasping them with the hands or by mouthing them (Fig. 29.14). Infants appear to be unaware of what actions they can cause or what actions occur independently. For example, if an infant’s hand should accidentally strike a mobile across the crib, the infant appears to enjoy watching the brightly colored birds move in front of them but does not attempt to hit the mobile again because they do not realize their hand caused the movement. Figure 29.14 Infants explore the world by mouthing objects or fingering them. This also helps them separate self from environment. At about 6 months of age, infants pass into a stage Piaget (1952) called secondary circular reaction. Now when infants reach for a mobile above the crib, hit it, and watch it move, they realize it was their hand that initiated the motion, and so they hit it again. By 10 months, infants discover object permanence. Infants are ready for peek-a-boo once they have gained this concept. They know their caregiver still exists even when hiding behind a hand or blanket and wait excitedly for them to reappear. As infants reach 1 year of age, they are capable of reproducing new events (they deliberately hit a mobile once, it moves, and they hit it again). They drop objects from a high chair or playpen and watch where they fall or roll. This is a frustrating activity for caregivers because it involves a great deal of reaching and picking up. It is an important activity for infants, however, because it confirms their awareness of the permanence of objects and how they are able to control events in their world. QSEN Checkpoint Question 29.3 QUALITY IMPROVEMENT The nurse is discussing object permanence with the parent. Which action by the infant best illustrates understanding of object permanence? a. The child looks for the parent after walking away.  b. The child cries when either hungry or lonely. c. The child prefers a large yellow ball to a small red one. d. The child smiles when the mobile on the crib jingles. Look in Appendix A for the best answer and rationale. The Nursing Role in Health Promotion of an Infant and Their Family The nursing role with infants is wide ranging because infants are so dependent on their caregivers for safety, learning, and emotional development. PROMOTING ACHIEVEMENT OF THE DEVELOPMENTAL TASK: TRUST VERSUS MISTRUST Erikson (1993) proposed that the developmental task of the infant period is to form a sense of trust (see Chapter 28). Infants who have numerous caregivers, who may be fed one day on a rigid schedule and the next only when they are hungry, who sometimes are treated roughly and sometimes gently, or who do not always have their needs met can have difficulty learning to trust. Cultures can vary in how they address care of an infant and promote trust. Variations in cultural influences for the same infant should be explored, so the infant is provided with consistency of care and can anticipate an expected response (Box 29.4). BOX 29.4 Nursing Care Planning to Respect Cultural Diversity Although development follows set patterns during the infant year, infant care is more dependent on cultural factors. One difference is in the way parents/caregivers carry their infants. In some families, infants are carried in the adult’s arms. Slings on the shoulders or hips may be another option. This enables the person carrying the infant to have their hands free for other activities. The frequency of infant bathing and hair shampooing varies with families. Bathing could be daily or every few days. Hair could be shampooed daily or less often. This may depend on the climate (temperature) or the availability of water for bathing. The use of diapers varies also. Families could use cloth or disposable diapers. It is important for infants to establish the ability to love, or trust, early in life in this way because development is sequential. If a first developmental step is not achieved, this can affect all future steps. In reference to trust, the result could be an adult unable to instill a sense of trust in their own child, perpetuating the difficulty of doing so from generation to generation. How do caregivers (or a nurse) encourage a sense of trust in an infant? Trust arises primarily from a sense of confidence that one can predict what is coming next. This does not mean caregivers should set up a rigid schedule of care for their infant. However, it does imply that parents/caregivers should study the infant’s reaction to activities and then establish a workable schedule based on that (e.g., breakfast, bath, playtime, nap, lunch, walk outside, quiet playtime, dinner, story, and bedtime). This gentle rhythm of care gives infants a sense of being able to predict what is going to happen and gives life consistency. All children thrive on routine such as the same story read repeatedly, the same bedtime rituals, or the same spoon every day for lunch. Infancy is not too early for children to learn family traditions such as decorating for a holiday because this type of repetition can help them feel secure in their world. Some caregivers have difficulty accepting routine as important to a child. They may be so tired of their own work schedules that they want to raise their children as free spirits. Do not discourage this philosophy; however, suggest a few modifications to instill some predictability into infants’ lives. Just as it is important that there is a rhythm to the care, it is also important that the care be mainly given by one person or by a core group of persons (Fig. 29.15). This person can be the parent(s), grandparent(s), a caregiver, a foster parent, or anyone who can give consistent care. For infants ill at birth who are hospitalized for months, this person is often a primary nurse or case manager. Encourage parents who are reluctant at first to interact with their infant not to feel self-conscious about talking to a baby who does not talk back. Pointing out the importance of such interactions and role modeling those while caring for children help parents use this type of stimulation as they care for their baby’s physical needs. Figure 29.15 An infant’s sense of trust develops through warm interpersonal relationships. Here, a parent and infant share a bonding moment. Discuss methods of childcare with alternative caregivers to prevent disrupting an infant’s routine. When a child is admitted to a hospital, document and list this information on an infant’s electronic record. Advocate for primary caregivers to make certain that not only will the number of caretakers for their child be limited but that caretakers will be actively interacting with their child. Passively caring for infants—not talking to them or touching or stroking them while feeding or changing them—amounts to little more than not being with them at all. Nursing actions designed to help an ill infant develop a sense of trust, in addition to individual caretaking, are detailed in Table 29.3. TABLE 29.3 WAYS FOR NURSES TO HELP AN ILL INFANT DEVELOP A SENSE OF TRUST Area of Care Nursing Actions Nutrition Encourage breastfeeding while the infant is hospitalized; provide privacy and support as necessary. Provide a breast pump for birthing parent to provide expressed milk for infant. Provide storage for milk, and lactation support. If a parent is not present to do so, hold the infant no matter what feeding method is used (e.g., gavage, total parenteral, oral, enteral). If this is not possible, hold infants for a time after or between feedings so that they receive holding equal to what they would ordinarily receive with being fed. If infant feeding is not taking oral intake, provide a pacifier (medical condition and parent preference considered) five or six times daily for sucking pleasure. Dressing change Use nonallergenic tape to avoid irritation while it is applied and reduce pain when removed. Use stockinet, rolled gauze, or Kling gauze to hold a bandage in place rather than tape if possible. To prevent chilling, be certain that irrigation solutions are warm; keep exposure during dressing changes to a minimum. Restrain only those body parts necessary for safety. Describe what you are doing in a nonthreatening tone of voice as you give care to give comfort. Medicine Flavor oral medicine to disguise disagreeable taste. Never add medicine to feeding as the infant may not administration finish the full feeding. Comfort the infant after injections or intravenous insertion by holding and rocking or immediately give the infant to a parent. Check intravenous sites frequently for infiltration and pain. Role model for caregivers how to hold the infant despite tubing and restraints. Rest Encourage caregivers to rock infants to sleep. Do this yourself if no parent is present. Always wake infants gently because it is frightening (for anyone) to be awakened by a stranger. If bed rest is necessary, check for irritated elbows, heels, and knees from rubbing against sheets; protect with long sleeves or pants or a Kling bandage. Combine care to avoid disturbing nap and sleep time with procedures or taking vital signs. Hygiene Check the temperature of bath water for comfort and to prevent chilling or burning. Change diapers frequently to reduce discomfort from irritation. To avoid caries, begin tooth brushing with first tooth. Pain Hold and comfort an infant in pain. Do not ask caregivers to restrain a child for a painful procedure. Allow caregivers to comfort the child afterward because that is a better parent role. Reduce painful procedures to a minimum (e.g., combine blood drawing so only one puncture is necessary for many tests). Stimulation Remember that infants focus longest on a human face. Face them directly to talk to them. Provide a crib mirror or a mobile because visual stimulation seems satisfying to an infant. If no mobile is available, create one from string or strips of adhesive tape, colored paper, cotton balls, or colored tongue blades. For safety, hang the mobile high enough for the infant to see but not reach. During the second half of the first year, infants need to try to crawl. Put a pad or sheet on the floor and encourage them to come to you while you stand by to offer reassurance. If contagion or immunosuppression is not a problem, bring the infant’s crib to the nursing desk where the infant can still interact with you while you do necessary paperwork. PROMOTING INFANT SAFETY Unintentional injuries are a leading cause of death in children from 1 month through 24 months of age (CDC, 2018a). Most unintentional injuries in infancy occur because caregivers either underestimate or overestimate a child’s ability. Nursing interventions that help caregivers become sensitive to their infant’s developmental progress, therefore, not only help establish sound caregiver–child relationships but also guard infant safety (Box 29.5). BOX 29.5 Nursing Care Planning Based on Family Teaching UNINTENTIONAL INJURY PREVENTION MEASURES FOR INFANTS Q. A parent is worried about keeping their 2-month-old safe. “How can I prevent accidents at this age?” the parent asks. A. Here are some tips to help prevent specific types of unintentional injuries: Potential Unintended Injury Prevention Measures General Be aware that the frequency of injury is increased when parents/caregivers are under stress. Take special precautions at these times. Choose babysitters carefully and explain and enforce all precautions when sitters are in charge. Aspiration Be certain any object an infant can grasp and bring to the mouth is either safe to eat or too big to fit in the mouth. Do not offer foods such as popcorn or peanuts because these are easily aspirated. Inspect toys and pacifiers for small parts that could be aspirated if broken off. Avoid the use of baby powder and corn starch. Falls Never leave an infant on an unprotected surface, such as a bed or couch, even if the infant is in an infant seat. Place a gate at the top and bottom of stairways; do not allow infant to walk with a pointed object in the hands or mouth. Do not leave a child unattended in a high chair; avoid using an infant walker. Motor vehicle Never transport an infant in an automobile unless the infant is buckled into an age-appropriate seat in the back seat of the car. The seat should be a rear-facing one until the infant is 6 to 12 months or per manufacturer’s guidelines for height and weight. Be aware of the proper technique for tethering the car seat to the car. Do not be distracted by an infant while driving. Do not leave an infant unattended in a parked car (the infant can become dehydrated from excess heat, can move the gear shift, or be abducted). Many driving apps have a child reminder alert when the destination is reached. Suffocation Allow no plastic bags within infant’s reach; do not use pillows in cribs. Store unused appliances such as refrigerators or stoves with the doors removed. Buy a crib that is approved for safety. Remove constricting clothing such as a bib or pacifier clip from shirt at bedtime. Drowning Do not leave infants alone in a bathtub or unsupervised near water (even buckets of cleaning water). Animal bites Do not allow an infant to approach animals; supervise play with family pets. Poisoning Never present medication as a candy; buy medications in containers with safety caps; put away in a high cabinet immediately after use. Never take medication in front of infants. Place all medication and poisons in locked cabinets or overhead shelves. Do not use lead-based paint in any area of the home. Hang plants or set on high surfaces. Post telephone number of the national poison control center by the telephone (1-222-1222). Burns Test warmth of fluids and food before feeding (use extra precaution with microwave warming). Do not smoke or drink hot liquids while holding or caring for an infant. Buy flame-retardant clothing for infants; turn handles of pans toward back of stove. Use a sunscreen on a child over 6 months when out in direct or indirect sunlight and limit the child’s sun exposure to less than 30 minutes at a time. Avoid direct sunlight. If a vaporizer is used, use a cool-mist, not a hot-mist type; remain in room to monitor so child cannot reach vaporizer. Monitor infants carefully near candles. Do not leave infants unsupervised near hot-water faucets. Keep a screen in front of a fireplace or heater.  Keep electric wires and cords out of reach; cover electrical outlets with safety plugs. General Be aware that some infants are more active, curious, and impulsive and therefore more vulnerable to unintentional injury than others are. Aspiration Prevention Aspiration is a chief injury threat to infants throughout the first year. Round, cylindrical objects are more dangerous than square or flexible objects in this regard. A 1-in. (3.2-cm) cylinder, such as a carrot or hot dog, is particularly dangerous because it can totally obstruct an infant’s airway. A deflated balloon can be sucked into the mouth, obstructing the airway in the same way. Educate caregivers who feed their infant formula not to prop bottles. By doing this, they are overestimating their infant’s ability to push the bottle away, sit up, turn the head to the side, cough, and clear the airway if milk should flow too rapidly into the mouth, allowing the infant to aspirate. Other instances of aspiration occur because caregivers underestimate their infant’s ability to grasp and place objects in their mouth. Even a newborn can wiggle to a new position to reach an attractive object such as a teddy bear with small button eyes. Newborns’ grasp and sucking reflexes automatically cause them to grasp and pull the object into their mouth. Caution caregivers to be certain nothing comes within an infant’s reach that would not be safe to put into the mouth. Using clothing without decorative buttons and checking toys and rattles to ensure they have no small parts that could snap off or fall out are good steps for caregivers to follow. A test of whether a toy could be dangerous if an infant puts it inside the mouth is whether it fits inside a toilet paper roll. If it does, it is small enough to be aspirated. For this reason, when solid foods are introduced, encourage caregivers to offer small pieces of hot dogs or grapes, not large chunks. Children under about 5 years should not be offered popcorn or peanuts because of the danger of aspiration. As infants become more adept at handling toys, caregivers need to reassess toys for loose pieces or parts. If caregivers are going to offer an infant a pacifier, they should use one that has a one-piece construction with a flange large enough to keep it from completely entering the child’s mouth (Fig. 29.16). Figure 29.16 Many infants enjoy sucking on a pacifier to help them fall asleep. This may also help prevent sudden infant death syndrome. Fall Prevention Falls are also a major cause of infant injuries. As a preventive measure, no infant, beginning at the newborn stage, should be left unattended on a raised surface. Normal wiggling can bring even a newborn to the edge of a bed, couch, or table top, resulting in a fall. Teach caregivers to be prepared for their infant to turn over by 2 months of age. From that time on, caregivers must be especially vigilant not to leave the baby unattended on a changing table or counter. If the child sleeps in a crib, the mattress should be lowered to its bottom position so the height of the side rails increases; rails should be no more than 2⅜ in. apart, narrow enough so that children cannot put their head between them. Two months is about the maximum length of time infants can safely sleep in a bassinet; they need the protection of a crib and high side rails before they turn over. All of these safety precautions apply to the hospital environment as well as to the home. Ensure there is no space between the mattress and headboard or an infant’s head could become trapped. Make sure cords from nursing call bells or other equipment are out of an infant’s reach. QSEN Checkpoint Question 29.4 EVIDENCE-BASED PRACTICE Borg et al. (2020) conducted a retrospect study on sink-bathing injuries. An analysis of 71 patients during an 8.5- year period revealed that infants under 1 year of age are most commonly afflicted. Families of low socioeconomic means were commonly afflicted. Of the 71 patients who met the inclusion criteria, 63% were male and 37% were female. The ages ranged between 0 and 60 months with an average age of 9.2 months. Burns most commonly occurred in the bathroom (65%), with all remaining burns occurring in the kitchen (35%). Infants were most often bathed by a parent (79%) followed by another adult (11%), grandparent (7%), and babysitter (3%). Of the circumstances reported, burns occurred in 73% of cases when the infant turned the hot- water faucet on or turned the cold-water faucet off. In half of those cases, the parent/caregiver was briefly distracted when the faucet was turned. In another 10%, the parent/caregiver turned the faucet in the wrong direction. Of the burns, 10% occurred when the running water temperature changed suddenly; 7% occurred when the water temperature was not checked before placing the infant in the sink. In those cases, burns occurred in 4% of infants bathed by a sibling and in 3% by an adult. Understanding the different circumstances surrounding sink-bathing burns allows more specific community education and efficient use of resources. Borg, B. A., Durgham, M., Shanti, C. M., & Klein, J. D. (2020). Sink bathing burns: A unique opportunity for an injury prevention initiative. Burns, 46(8), 1875–1879. https://doi.org/10.1016/j.burns.2020.05.016 Based on the study, the nurse is most concerned about which remark by the parent of a 2-month-old? a. “I am not sure what my hot-water temperature is set at, I can check.” b. “I don’t give my baby a bath every night as I am so tired by the end of the day.” c. “I have one of those water temperature readers in a floating duck that I use when bathing.” d. “I live in an apartment and can’t control my hot-water temperature.” Look in Appendix A for the best answer and rationale. Car Safety Teaching car safety for infants (as well as for the whole family) is an important protective health measure. The use of car seats for newborns is discussed in Chapter 18. Infants should be placed in backward-facing seats in the back seat because an inflating front seat airbag could suffocate an infant (AAP, 2015b). Backward-facing car seats should continue to be used until the child reaches the highest weight or height allowed by the car safety seat’s manufacturer. QSEN Checkpoint Question 29.5 SAFETY The nurse reviews infant safety with a parent. It is most important to teach the parent about preventing which common injuries among infants? a. Drowning and hypersensitivities b. Poisoning and suffocation c. Auto accidents and burns d. Aspiration and falls Look in Appendix A for the best answer and rationale. Safety With Siblings As infants become more interactive at about 3 months of age, older siblings grow more interested in interacting with them. You may need to remind caregivers that children under about 5 years, as a group, are not responsible enough or knowledgeable enough about infants to be left unattended with them. They might introduce an unsafe toy or engage in play that is too rough for an infant. Some preschoolers may be so jealous of a new baby they will physically harm an infant if left alone (Kramer, 2018). Bathing and Swimming Safety As babies begin to develop good back support, many caregivers begin to bathe them in an adult tub. Caution caregivers not to leave an infant unattended in a tub, even when propped up out of the water or sitting in a bath ring or bath seat. Normal wiggling can easily cause a baby to slip down under the water. This applies to a hospital setting as well. Many communities offer infant swim programs for babies as young as 6 months. This does not teach them to swim; therefore, the parent/caregiver should not be overconfident about their infant’s ability to be safe in the water. Childproofing Toward the end of pregnancy, caregivers need to begin preparing for their infant’s arrival by childproofing their home. As soon as infants begin teething at 5 to 6 months, they chew on any object within reach to lessen gumline pain. Remind caregivers to thoroughly check for possible sources of lead paint, such as painted cribs, playpen rails, or windowsills before this time to avoid lead poisoning (CDC, 2018b). If an infant is going to play on the floor, urge caregivers to move furniture in front of electrical fixtures or buy protective caps for outlets. Infants are especially fascinated by the holes in electric outlets and will probe them with (often wet) fingers. Caregivers may need to install safety gates at the top and bottom of stairways as additional safety measures before the infant crawls. Urge caregivers to move all potentially poisonous substances from bottom cabinets and store them well out of their infant’s reach. Infants of any age should not be left unattended in carriages, high chairs, grocery shopping carts, or strollers. Baby walkers are extremely dangerous because infants can maneuver them near stairways and fall the length of the stairs. When infants begin creeping, remind caregivers to recheck bottom cabinets and stairways for safety. When the child begins to walk, higher areas, such as low tables, need to be cleared of dangerous items. In a hospital setting, assess low counter areas for dangerous objects. Do not leave possibly dangerous supplies in an infant’s room. By 10 months, achievement of a pincer grasp makes infants able to pick up very small objects. Remind caregivers to check play areas or areas such as tabletops for pins or other sharp objects that could be swallowed. At this point, some of an infant’s toys may now be 10 months old and need to be checked to be certain they are still intact and safe. Although infants can seem very independent and able to take care of themselves toward the end of the infant year, their judgment about what situations could be dangerous is immature. When walking begins around this time, additional childproofing measures need to be considered, including attention to the infant’s access to open doors and stairs (Fig. 29.17). Figure 29.17 Once walking begins, the extended range of activities brings an infant in contact with potentially dangerous places or objects unless the house is childproofed. The bathroom is an important room in which to begin childproofing. PROMOTING NUTRITIONAL HEALTH OF AN INFANT Feeding From Birth Through 6 Months Feeding recommendations for infants from birth through 6 months are to provide human milk exclusively via breastfeeding or expression and stored in a bottle. Human milk is the ideal form of nutrition for infants. It provides all the necessary nutrients, protective factors against disease, and properties that support infant health and growth and development. Infants exclusively receiving human milk or partial human milk feedings (supplemented with formula) should receive 400 IU of vitamin D supplement daily starting at 2 weeks of age (AAP, 2017). Infants exclusively on formula do not need vitamin D supplementation as it is included in the formula. Human milk provides immunity from infections from which the breastfeeding parent is immune. This can include the COVID-19 virus if the breastfeeding parent is fully vaccinated. Recent reports have shown that those persons who are breastfeeding and who have received mRNA COVID-19 vaccines have antibodies in their human milk, which could help protect their infants (CDC, 2021). More data are needed to determine what protection these antibodies may provide to the infant. U.S. data show that about 84% of infants born in 2017 were ever fed human milk, with only 25% fed human milk exclusively through age 6 months and 35% continuing to receive any human milk at age 12 months. Nearly 25% of infants were fed some human milk beyond age 12 months, with about 15% of toddlers receiving human milk at age 18 months (United States Department of Agriculture [USDA], 2020). Nurses can support and promote breastfeeding in the ambulatory, community, and hospital settings when interacting with parents/caregivers of infants and toddlers. Families may have a number of reasons for not providing human milk for their infant. The infant may be adopted, or the birth parent may be unable to produce a full milk supply or to pump and store milk safely due to family or workplace pressures (USDA, 2020). If families do not have sufficient human milk for their infant but want to feed their infant human milk, they may look for alternative ways to obtain it. It is important for the family to obtain pasteurized donor human milk from a safe source, such as an accredited human milk bank that has screened its donors and taken appropriate safety precautions. When human milk is obtained directly from individuals or through the internet, the donor may not have been screened for infectious diseases, and it is unknown whether the human milk has been collected or stored in a way to reduce possible safety risks to the infant (USDA, 2020). Home-made infant formulas and those that are improperly and illegally imported into the United States without mandated U.S. Food and Drug Administration (FDA) review and supervision should not be used. Toddler milks or toddler formulas should not be fed to infants, as they are not designed to meet the nutritional needs of infants (USDA, 2020). Cow’s milk is not recommended prior to 1 year of age. The protein in cow’s milk is difficult for an infant to digest, possibly leading to intestinal irritation that causes slight but continuous gastrointestinal bleeding, which may result in anemia. If human milk is unavailable, infants should be fed an iron-fortified commercial infant formula (i.e., labeled “with iron”) regulated by the FDA and based on standards that ensure nutrient content and safety. Infant formulas are designed to meet the nutritional needs of infants and are not needed beyond age 12 months. It is important to take precautions to ensure that expressed human milk and prepared infant formula are handled and stored safely (Box 29.6) (USDA, 2020). BOX 29.6 Proper Handling and Storage of Human Milk and Infant Formula Wash hands thoroughly before breastfeeding, expressing human milk, or preparing to feed human milk or infant formula. If expressing human milk, pump parts should be thoroughly cleaned prior to use. If preparing powdered infant formula, use a safe source of water and follow instructions on the label. Refrigerate expressed human milk within 4 hours. It may be stored in the refrigerator for up to 4 days and in the freezer for 4 months. Think “four, four, four” as a pneumonic for remembering storage guidelines. Previously frozen and thawed human milk should be used within 24 hours. Thawed human milk should never be refrozen. Refrigerate prepared infant formula for up to 24 hours. Hospital guidelines and especially neonatal intensive care unit (NICU) guidelines may be stricter regarding the time frame as there is increased risk of infection in the hospital compared to the home environment.  Do not use a microwave to warm human milk or infant formula as it can heat unevenly and contain areas that can cause a burn. Warm by placing the sealed container of human milk or infant formula in a bowl of warm water or under warm, running tap water. Once it has been offered to the infant, use or discard remaining liquid within 2 hours for human milk or 1 hour for infant formula, as bacteria growth develops. Thoroughly wash all infant feeding items, such as bottles and nipples. For infants younger than 3 months of age, infants born prematurely, or infants with a compromised immune system, sanitizing feeding items may be recommended. United States Department of Agriculture. (2020). Dietary guidelines for Americans 2020–2025. https://www.dietaryguidelines.gov Feeding From 6 Months to 1 Year From 6 months to 1 year of age, continue to feed infants human milk through breastfeeding or in a bottle obtained through expression through the first year of life, and longer if desired. Infants fed human milk exclusively or a mixed feeding of human milk and formula need supplementation with fluoride and iron at 6 months of age. Iron stores from transfer in utero are depleted at 6 months of age. Feed infants iron-fortified infant formula during the first year of life when human milk is unavailable. After 6 months of age, if the water supply does not contain fluoride, it may be provided to the infant as a supplement. Infants are not ready to digest complex starches until amylase is present in saliva at approximately 2 to 3 months. Biting movements begin at approximately 3 months. Chewing movements do not begin until 7 to 9 months. Therefore, foods that require chewing should not be given until this age. In addition to these guidelines, the extrusion reflex needs to fade before infants accept food readily. With the extrusion reflex intact, when anything is placed on the anterior third of an infant’s tongue, it is automatically extruded or thrust out of the mouth by the tongue (Fig. 29.18). This is a lifesaving reflex in early infancy because it prevents infants from swallowing or aspirating foreign objects that touch the mouth. The reflex fades at 3 to 4 months at about the same time the gastrointestinal tract has matured to be ready to digest solid food. Figure 29.18 A 3-month-old baby demonstrates an extrusion reflex. Caution parents/caregivers not to interpret this action as a food dislike but recognize it as the reflex action that it is. Introduce infants to nutrient-dense complementary foods after 6 months of age. This may include potentially allergenic foods along with other complementary foods. Encourage infants to consume a variety of foods from all food groups. Include foods rich in iron and zinc, particularly for infants fed human milk. About 32% of infants in the United States are introduced to complementary foods and fluids prior to age 4 months of age, highlighting the importance of providing guidance and support to parents/caregivers on the appropriate time to introduce complementary foods. Early introduction of complementary foods and fluids is higher among infants receiving infant formula (42%) or a combination of infant formula and human milk (32%) than among infants exclusively fed human milk (19%) (USDA, 2020). As infants wean from human milk or infant formula, transition to a healthy dietary pattern. Because children’s nutritional needs vary so much from infancy through adolescence, the recommended allowances of calories, protein, vitamins, and minerals vary with each period of development (see Chapter 28). The entire first year of life is one of extremely rapid growth, so a high-protein, high-calorie intake is necessary. Calorie allowances can be gradually reduced during the first year from a level of 120 calories per kilogram (55 calories per pound) of body weight at birth to approximately 100 calories per kilogram (45 calories per pound) of body weight at the end of the first year. Infants are capable of approximating their lips to a cup, and they can drink effectively from one at about 9 months of age. The sucking reflex begins to diminish in intensity between 6 and 9 months, which makes this the time to consider weaning from a bottle. At approximately 6 months of age, infants become interested in handling a spoon and beginning to feed themselves. Their coordination, unfortunately, has not developed enough for them to use a spoon without a great deal of spilling, so they are much more adept at feeding themselves with their fingers (Fig. 29.19). Caregivers concerned with neatness can spread newspapers, a plastic tablecloth, or a towel on the floor around a high chair to catch most of the dropped food, and then let the child practice. When an infant becomes fatigued or frustrated with attempts at self-feeding, a caregiver can help without issue. Figure 29.19 Self-feeding is not always a neat process for young children. Complementary Foods and Fluids to Meet Energy and Nutrient Requirements Parents/caregivers are encouraged to introduce foods across all the food groups, including items that fit within a family’s preferences, cultural traditions, and budget. Complementary foods and fluids should be rich in nutrients, meet calorie and nutrient requirements during this critical period of growth and development, and stay within limits of dietary components such as added sugars and sodium. Although the USDA Dietary Guidelines do not provide a recommended dietary pattern for infants aged 6 through 11 months, infants should be on the path to a healthy dietary pattern that is recommended for those aged 12 through 23 months (USDA, 2020). In the United States, some dietary components are of public health concern for infants and toddlers. Iron is a dietary component of public health concern for underconsumption among older infants aged 6 through 11 months who are fed primarily human milk and consume inadequate iron from complementary foods. Older infants who are fed primarily human milk also underconsume zinc and protein from complementary foods and all older infants notably underconsume vitamin D, choline, and potassium. During the second year of life, the dietary components of public health concern for underconsumption are vitamin D, calcium, dietary fiber, and potassium, and for overconsumption are added sugars and sodium. Developmental Readiness for Beginning to Eat Solid Foods The age at which infants reach different developmental stages will vary. Typically, between ages 4 and 6 months, infants develop the gross motor, fine motor, and oral skills necessary to begin to eat complementary foods. As an infant’s oral skills develop, the thickness and texture of foods can be varied gradually. Signs that an infant is ready for complementary foods include: Being able to control the head and neck Sitting up alone or with support Bringing objects to the mouth Trying to grasp small objects, such as toys or food Swallowing food rather than pushing it back out onto the chin (USDA, 2020) Providing Safe Feeding Infants aged 6 months to a year should be given age-appropriate and developmentally appropriate foods to help prevent choking. Foods such as hot dogs, candy, nuts and seeds, raw carrots, grapes, popcorn, and chunks of peanut butter are some of the foods that can be a choking risk for young children. Parents/caregivers are encouraged to take steps to decrease choking risks like: Offering foods in the appropriate size, consistency, and shape that will allow an infant to eat and swallow easily Making sure the infant or young child is sitting up in a high chair or other safe, supervised place; this is important to keep in mind as well when feeding infants in a hospital setting. Ensuring an adult is supervising feeding during mealtimes Not putting infant cereal or other solid foods in an infant’s bottle; this could increase the risk of choking and will not make the infant sleep longer (USDA, 2020). Supplemental Vitamin B12 Human milk has sufficient vitamin B12 to meet infant needs unless the breastfeeding parent’s vitamin B12 status is inadequate. This can occur for different reasons, including when the breastfeeding parent eats a strictly vegan diet without any animal source foods. When the breastfeeding parent is at risk for vitamin B12 deficiency, human milk may not provide sufficient vitamin B12. In these cases, the breastfeeding parent and/or the infant fed human milk may require a vitamin B12 supplement. Parents, caregivers, and guardians should consult with a healthcare provider to determine whether supplementation is necessary. Introducing Infants to Potentially Allergenic Foods Potentially allergenic foods (e.g., peanuts, egg, cow milk products, tree nuts, wheat, shellfish, fish, and soy) should be introduced when other complementary foods are introduced to an infant’s diet. Introducing peanut-containing foods in the first year of life reduces the risk that an infant will develop a food allergy to peanuts. Liquid cow’s milk should be introduced at age 12 months or later. There is no evidence that delaying introduction of allergenic foods beyond when other complementary foods are introduced helps to prevent food allergy (USDA, 2020). Introducing Iron-Rich Foods to Infants at 6 Months Iron-rich foods (e.g., meats and seafood rich in heme iron and iron-fortified infant cereals) are important components of the infant’s diet from age 6 thr