Growth and Development of the Child
General Applications:
Best indicator of good health is a steady increase in size, weight, height, head/chest circumference, with
normal fontanel changes….
Patterns of Growth and Development
Cephalocaudal: head to tail
Proximodistal: midline to peripheral
Differentiation: simple to complex
Play: the work of childhood
Factors Influencing Pediatric Health:
Environment
Genetics
Well Child Visits:
Infant: 2 weeks; 2-4-6-9-12 months
Toddlers: 15, 18-24 months
Preschoolers: 3, 4, 5 years
School Age: annually from 6-12 years
Adolescence: Annually from 13-18 years
Anticipatory Guidance: Consider age appropriate topics to review each visit (e.g. preschooler entering
school-age group-What safety issues might be coming up?)
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Poison Control: 1-800-222-1222
Infants:
Growth & Development: Infants Erikson’s Psychosocial Development-Trust vs Mistrust
Birth to 1 year-major task is development of trust in the caregiver
Birth weight doubles in 6 months and triples by 1 year
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Communication:
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Fontanels: Anterior-9 months -2 years Posterior 1-2 months
Separates self from objects by 4-8 months
Object Permanence: understands object or person exists when not seen, heard, felt @ 6 months
Stranger Anxiety: 12-15 months
Nutrition:
Breast is best
Formula: iron fortified 12 months
Solids: 4-6 months
Sequence of introduction: iron fortified rice cereal->fruits/vegetables->meats->juices (@ 6 months and
diluted-rinse mouth after juices)
Avoid honey/peanut butter and whole milk until 1 year
Chopped table foods by 12 months
Safety Concerns:
Water heaters below 120°
Car seats
Heat related injuries (cars)
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Apnea monitoring (ALTE) pages 372-74
Immunizations:
DTaP, Hib, pneumococcal: 2, 4, 6, and 15-18 months
Polio: 2, 4, and 6-18 months
Hepatitis B: birth, 2, and 6-18 months
RV (rotavirus):2, 4, 6 months
Influenza: 6 months and annually
MMR & Varicella: 12-15 months
Hepatitis A: 12 and 18 months
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Fears and reaction to illness:
Newborns: reflexive startle response (Moro’s) to loud noise and sudden movement
Young Infants: respond to pain with generalized body responses (loud crying, facial grimacing)
Older Infants: generalized body responses, deliberate withdrawal from painful stimuli, loud crying, facial
grimacing, anger, physical resistance.
Reaction to hospitalization:
Under 3 months: will tolerate short term hospitalization if provided with a nurturing person who meets
physical needs
4-6 months: recognizes mother and father as separate from self (separation anxiety); experiences
anxiety with hospitalization
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Impact of hospitalization on infant development:
Task: Trust vs. Mistrust
Impact: bonding delayed related to imposed separation
Sensorimotor Development: delayed with confinement
Affection: may associate touch with pain; affecting ability to give or receive affection
Nursing Interventions:
Positive tactile stimulation
Consistent caregiver
“Safe place” (no treatments)
Decrease parental anxiety
Toddler:
Growth & Development:
Erikson’s-Autonomy vs. Shame/Doubt: 18 months-3 years
Major task: achieving independence and self-control
Autonomy: achieve ability to delay gratification (self-control)
Symbolizes independence by controlling body secretions and saying “No”.
Allow simple decision making, assess for aggressive behaviors resulting in poor self-confidence, lack of
Pride, inability to perform, sense of being controlled by others and may exhibit rage against them.
Communication:
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Toddlers have socialization issues:
Object permanence-fully developed by 24 months
Ritualistic behaviors-exhibits need for sameness; provides sense of comfort and security
Negativism: “No”, egocentric
Parental separation anxiety usually peaks at 18-20 months
Nutrition:
Experience physiologic anorexia due to being “picky eaters”
Food jags-eating same foods over and over
Limit milk intake: iron deficiency anemia
Clinical manifestations of food allergies (pg. 359)
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Safety concerns
Primarily the same as infants with increased vigilance needed around water; also household and
environmental poisoning
May not chew foods thoroughly
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Immunizations: see schedule
Play:
Toys should enhance motor/locomotion skills, language development, gross and fine motor skills
Parallel play-side by side but not interacting
Imaginative-make believe and role-play
Provide blocks, wheel toys, push toys, puzzles (lg pieces), dolls, housekeeping toys, play phones, stories
(read to the children) and short songs with action and rhythm
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Fears and reactions to illness:
Concept of body is poorly defined therefore intrusive procedure are extremely anxiety producing
Pain response is similar to infants and may be based on previous experiences
Fears:
Loss of parents (separation anxiety)
Stranger anxiety
Loud noises
Going to sleep
Large animals
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Reaction to death: Infant and toddler:
Both have a very limited understanding of death
More affected by the change in routine
May become more attached to the remaining parent; display regression and increased separation
anxiety.
Reaction to hospitalization-toddlers:
Regression
Loss of control R/T physical restrictions, loss of routine and rituals, dependency and fear of bodily injury
and pain
Separation from parents is viewed as abandonment…presenting 3 distinct phases:
 Protest-toddler verbally cries, clings to parent or physically attacks others, is inconsolable
 Despair-disinterested in environment, displays passivity, depression and loss of appetite,
apathetic
 Detachment (denial)-makes superficial adjustment, responding without enthusiasm to others
often ignoring parents.
Impact on child development
Task: Autonomy vs. Shame /doubt- child will often regress with the loss of control and newly discovered
independence.
Interventions:
Encourage continued mobility (wagons, outing with family, etc.) while ensuring safety
Encourage parents to work on skills they are trying to master @ home
Promote parental attachment during absences
Maintain consistent limits and schedules as much as possible
Preschooler:
Ages 3-5 years
Growth & Development: Initiative vs. Guilt
Characteristics: energetic, enthusiastic, intrusive learners
Expected growth milestones:
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Task: Initiative vs. Guilt
Concept of animism: inanimate objects are alive or have lifelike qualities
Highly active imaginations and fantasy thinking-things they don’t understand may be filled in with
imagination
Learning occurs in 4 ways:
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 Imitation ___________________________________________________________
 Experimentation _____________________________________________________
 Repetition __________________________________________________________
 Reinforcement ______________________________________________________
Play:
Associative: interactive and cooperative
Develops sexual identity
Toys: promote language and motor skills
 Motor skills: tricycles, gym sets, sandboxes, wading pools
 Fine motor: large blocks, puzzles, crayons, simple crafts
 Language: sing a long songs, nursery rhymes, books
 Imitative and imagination: dress up, dolls, play tents, puppets, housekeeping toys
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CONSTANT SUPERVISION REQUIRED!
Nutrition:
Picky eaters, grazers, monitor nutritional balance
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Safety:
Auto safety
Water
Injury prevention:
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Fears and reaction to illness: MORE FEARS THAN ANY OTHER AGE GROUP
Common fears:
 The dark
 Being left alone (esp. at bedtime) night terrors
 Animals
 Ghosts
 Bodily mutilation, pain, objects or people associated with painful experiences
 Magical thinking cause the preschooler to view illness as a punishment for a misdeed
 Fears of mutilation make the preschooler fearful of intrusive procedures (rectal thermometers,
catheters, injections, etc.)
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Immunizations Recommendations:
See schedule
Parent teaching:
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Reaction to hospitalization:
Primary defense: regression and refusal to cooperate
Sense of loss of control because they experience a loss of their own power
Fear bodily injury and pain=fear of mutilation and intrusive procedures
Interpret hospitalization as punishment and parental separation as a loss of control
Impact of hospitalization: loss of accomplishments (walking, talking, controlling basic body functions)
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Common nursing interventions for the hospitalized preschooler
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Simple concrete explanations
Advance preparation
Verbal explanations should be aided with pictures, models, equipment, medical play
Dispel magical thinking
School Age:
Age: 5-11
Growth & Development: School age, Industry vs. Inferiority
Industry springs from the development of trust and from a desire for accomplishment
Inferiority stems from sense of failing to meet standards set for self or by others; unrealistic
expectations. May be overly passive or aggressive to hide feelings of inadequacy.
Peers, play and competitive games important
Play
Cooperative-define and give an example
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Comprehends rules, rituals of games, board games, jump rope, organized sports
Enjoys collections of items, develops hobbies (stamps, coins, cards, etc.)
 This illustrates object permanence, preoperational thinking and an ability to use abstract
symbols
Provide construction toys: models, cars, planes, crafts
Good eye-hand coordination
Nutrition:
Higher risk for obesity
Growth spurts and some accompanying problems
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Immunizations:
Tdap: 11-12 years and then every 10 years
HPV vaccine: 11-12 years (3 doses)
Meningococcal: 11-12 years and college entrance
Safety:
Introduce sex education
Injury prevention-common injuries
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If asked about exposure to TV and other electronics what is the suggestion for daily viewing?
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Fears and reactions to illness
Common Fears:
Failure at school
Bullies
Intimidating teachers
Something “bad” happening to parents
Teasing and ridicule by others
Peer pressure
Able to perceive external forces are causes of illness
Aware of significance of different diseases (understand that cancer is worse than a “cold”)
Reaction to death: School age
View death as irreversible, but not inevitable
Adult concept of death by age 10; understand death is irreversible and permanent (this may have a
great deal to do with parent’s experience)
May believe death serves as punishment for wrongdoing
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Greatest fear is of bodily mutilation associated with death; very inquisitive about what happens to body;
great curiosity about funerals
May deny sadness and attempt to act like an adult
Common behaviors: problems in school, psychosomatic complaints, acting out behaviors
Reaction to Hospitalization:
Primary defense: reaction formation-unconscious defense mechanism in which child assumes the
opposite of the impulse they feel
Example: ___________________________________________________________________________
React to separation by demonstrating loneliness, boredom, isolation, or depression. May also show
aggression, irritability and inability to relate to peers and siblings
Sense of loss of control is related to enforced independence and altered family roles
Fear of bodily injury and pain results from fear of illness, disability and death
Impact on child development
Remember the task is Industry vs. Inferiority
Mastery of the task is dependent on ability of the child to cooperate and compete with others
Impact: independence is compromised by feelings of inadequacy or inferiority.
Nursing Interventions:
 Provide choices
 Encourage peer contact
 Focus on unique abilities/identify realistic goals
 Identify “normal” things they can do while in the hospital (example-if possible let them wear
their own clothes)
 Aid explanations with diagrams, pictures, and models
Adolescent:
Age: 12-18
Growth and development: Identity vs. Role Confusion
Pubertal growth spurt earlier in girls than boys
Role confusion: doubt and confusion about their role in life
No personal goals, relationships often superficial and brief
Lacks self-confidence, exhibited as delinquent and rebellious behaviors
Reasons for non-resolution of task:
 Nurtured in dependent position by parents
 Not allowed active role in decision making
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Inconsistent discipline-overly harsh or absent
Parental rejection or frequent “parent shifting”
Psychosocial
Impulsive and reckless-invincible
Search for identity
A group identity-Greatly influenced by peers
Vocational-work habits solidify
Sexually-increased interest in the opposite sex
Mood swings
Maturation of thought processes-from concrete to abstract
Others (maybe related to school shootings…?)
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Safety:
Accidents leading cause of death
Examples:
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Health Promotion:
Educate:
Substance abuse: drugs, alcohol, bullying, __________________________________________________
Immunizations: (see Kee, Hayes, McCuistion -pg 509)
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Fears and reaction to illness
Common fears:
 Relationship with opposite sex
 Homosexual feelings
 Ability to assume adult roles
Concern of illness focus on:
Alterations in body image
Separation from peers
Illness as punishment (12-14 years)
Restricted independence due to confinement
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Reaction to death: adolescent
Adult concept of death: irreversible, universal and inevitable
Death seen as personal but distant
Conflict with invincibility and fear of death
Common reactions/behaviors related to death:
 Loneliness, sadness, fear, depression, acting out behaviors may include risk taking, delinquency,
suicide attempts
Reaction to Hospitalization
Primary defense mechanism: denial and displacement (displacing emotion from undesirable object to
more desirable)–throwing a cup instead of hitting a nurse
Sense of loss of control is related to loss of identity and forced dependence, may cause adolescent to
react with rejection, uncooperativeness, self-assertion, frustration or withdrawal from peers
Fear of mutilation and sexual changes
Separation from peer group may result in withdrawal, loneliness or boredom
Impact on child development of the adolescent: task- Identity vs. Role Confusion with impact on the
alteration of newly acquired roles.
Difficult time due to importance placed on self-image and sexuality-do not want to be different as that is
unacceptable.
Nursing Interventions
 Allow active decision making role
 Promote contact with peers
 Praise for accomplishments
 Deliver information sensitively
 Be honest about treatment and consequences
 Stress importance of cooperation and compliance
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Some notes:
What are the stages of despair? How does the child exhibit them?
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When does voluntary grasp develop? ______________________________________________________
Can change from breast milk to ___________________________ at 5 months.
What are recommendations for position of sleep and why?_____________________________________
Is it ok for an infant to reposition themselves?
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What might a finding of enlarged and warm cervical nodes suggest?
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Preferred sites for injections? What size needle? How much medicine per injection?
What does the finger-nose test indicate? ___________________________________________________
Add any other information you want to remember or feel is appropriate and
interesting.
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