Chapter 10.pdf
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BIOLOGIC DEVELOPMENT
Infants develop fine and gross motor skills in an orderly head-to-toe and center-toperiphery sequence.
Proportional Changes
Infants gain 1.5 lbs per month until age 5 months, when their birth weight has
doubled. The second 6 months are slower, but by 1 year the birth weight has tripled.
The average height of an infant increases by 2.5 cm (1 inch) per month from birth to
6 months, and by half that amount per month from 4 to 6 months to 1 year of age.
The average head size increases by 33% by 1 year of age.
The previous statements are general guidelines only; use the appropriate growth
charts reflecting weight for length and head circumference in each case to determine
appropriate growth parameters.
The brain grows 2.5 times during the first year of life, and new reflexes that influence
motor development appear.
The chest becomes more adult-looking, with the lateral diameter becoming larger
than the anteroposterior diameter. The heart grows less rapidly than the rest of the
body.
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Maturation of Systems
Other organ systems also change and grow during infancy, including the respiratory
rate slowing somewhat and the parachute reflex appearing at approximately 7
months.
Infants have a visual preference for looking at the human face, and this preference
develops in a developmental sequence. At age 6 months, infants can distinguish
between familiar and strange faces.
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Infancy is characterized by less protection against infection, diminished ability to
produce mucus, small airways, and less elastic recoil in the rib cage. The infant must
breathe twice as fast as the adult to provide the body with the needed amount of
oxygen.
During infancy, the heart rate slows and the rhythm is sinus arrhythmia, and the
blood pressure changes during varying states of activity and emotion.
During the first year of life, significant hematopoietic changes occur. Fetal
hemoglobin (HgbF) depresses the production of erythropoietin, a hormone released
by the kidney that stimulates RBC production, and thus results in a decreased
number of RBCs.
The digestive processes of full-term newborn infants are relatively immature. Human
milk has properties that partially compensate for decreased digestive enzymatic
activity, thus enabling the infant to receive optimum nutrition during the first several
months of life.
Infants do not achieve adult levels of fat absorption until 4 to 5 months of age, when
pancreatic enzymes begin to break down protein and fat.
During infancy, the digestive processes are immature, and the child's stomach
enlarges to accommodate a greater volume of food. This makes the child susceptible
to respiratory problems, and the eustachian tube closely communicates with the ear,
allowing infection to ascend from the pharynx to the middle ear.
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The development of the mucosa-associated lymphoid tissue occurs during infancy,
and is believed to prevent colonization and passage of bacteria across the infant's
mucosal barrier. Probiotics may have a significant role in helping the gastrointestinal
tract establish a "good" bacterial colonization.
During infancy, the skin's ability to contract and muscles to shiver in response to cold
increases, and the peripheral capillaries respond to changes in ambient temperature
to regulate heat loss. Adipose tissue insulates the body against heat loss.
At birth, the infant's body weight is 75% water. As the percentage of body water
decreases, the amount of extracellular fluid (ECF) increases, predisposing the infant
to more rapid loss of total body fluid and, consequently, dehydration.
The immaturity of the renal structures predisposes the infant to dehydration. The
infant's urine output is low and has a low specific gravity, and it increases to 60 to 80
ml/kg/24 hr as the infant grows.
At birth, the endocrine system is adequately developed, but its functions are
immature. The infant is vulnerable to imbalances in fluid and electrolytes.
The liver is the most immature of all the gastrointestinal organs throughout infancy. It
develops after the first couple of weeks of life.
Sucking activity can occur in utero as early as 15 to 18 weeks of gestation, and
complete maturation of sucking, swallowing, and breathing patterns is usually
synchronized by 34 to 36 weeks, although some sucking and swallowing synchrony
skills are seen by 30 to 33 weeks.
Swallowing (deglutition) is the ability to collect food and propel it into the esophagus.
The infantile swallow reflex moves food by gravity down the tongue and along the
sides of the mouth.
As the infant grows, the tongue becomes smaller and more motile, the orofacial
muscles develop, and teeth erupt. The swallow reflex is significantly different, and
the tongue remains behind the central incisors.
Infants also exhibit a reflexive swallow called the Santmyer swallow. This reflex may
be useful for administering fluids or medications.
The immune system undergoes numerous changes during the first year of life.
Maternal immunoglobulin G (IgG) levels gradually fall as the newborn produces
limited IgG, and the infant is at higher risk for infections during the first 6 to 12
months of life.
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The neonate is born with some ability to hold the head erect and reflexively assumes
the postural tonic neck position when supine. Several of the primitive reflexes have
significance in terms of development of later gross motor skills.
The asymmetric tonic neck reflex prevents the infant from rolling over, and the
symmetric tonic neck reflex helps the infant assume the crawl position.
Full-term newborns can lift and turn their head from side to side when prone, but
cannot lift their head out of a pillow or soft surface when lying prone. By 3 months of
age, head control is well established.
During infancy, corticotropin (ACTH) is produced in limited quantities, and the
feedback mechanism between ACTH and the adrenal cortex is immature. This
causes blood glucose levels to remain labile.
Fine Motor Development
Infants start to use their hands to grasp objects at 2 to 3 months of age. At 5 months
they can voluntarily grasp an object and by 8 to 9 months they can use a crude
pincer grasp.
Infants can hold their bottle, grasp their feet, and feed themselves a cracker by 6
months of age. By 7 months they can transfer objects from one hand to the other,
and hold a cube in each hand simultaneously.
A full-term infant can sit up unsupported by 8 months of age and can maneuver from
a prone to a sitting position by 10 months of age.
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Sitting ability follows progressive head control and straightening of the back. At about
4 months, the child can sit alone, leaning forward on the armrest.
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Failure to learn delayed gratification leads to mistrust. In the first 3 to 4 months, food
intake is the most important social activity in which the infant engages, and the
newborn can tolerate little frustration or delay of gratification.
The next social modality involves grasping and is initially reflexive. The parents'
holding on and touching is pleasurable tactile stimulation for both the child and the
parents, and is extremely important in the total process of acquiring trust.
Developing a Sense of Trust (Erikson)
Erik Erikson's (1963) phase I (birth to 1 year) is concerned with acquiring a sense of
trust while overcoming a sense of mistrust. The relationship between the parent and
child and the care the infant receives are crucial for the development of a strong
sense of self.
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Sensorimotor Phase (Piaget)
The period from birth to 24 months is called the sensorimotor phase and is
composed of six stages.
During the second stage of teething, infants learn that they can hold onto what is
their own and control their environment. However, biting causes the mother to
become upset and withdraw the breast.
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From birth to 1 month, infants use reflexes to express individuality and temperament.
These reflexes are the beginning of associations between an act and a sequential
response.
Infants progress from reflexive behaviors to simple repetitive acts to imitative activity
during the sensorimotor phase. They learn to separate themselves from other
objects in the environment and to recognize object permanence.
The last major intellectual achievement of this period is the ability to use symbols,
which allows the infant to think about time and space.
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DEVELOPMENT OF BODY IMAGE
Infants' body image parallels sensorimotor development. Their mouth is the principal
area of pleasurable sensations, and they receive emotional satisfaction from others
who smile back.
Infants learn that they are distinct from their parents and that parts of their body are
useful. This helps them develop a positive self-image.
DEVELOPMENT OF GENDER IDENTITY
Infants begin to develop their gender identity in utero because of hormonal
influences that are not entirely understood. Their gender identity is established by 2
to 3 years of life and is influenced by environmental, biologic, and sociocultural
factors.
Infants begin to imitate sounds and simple gestures, play with objects, and develop a
sense of permanency. These processes are critical for the development of parentchild attachment and separation anxiety at 6 to 8 months of age.
Infants use previous behavioral achievements as the foundation for adding new
intellectual skills to their expanding repertoire. They begin to associate symbols with
events and learn from the object itself, in contrast to the second stage, in which they
learn from the type of interaction between objects or individuals.
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During the formation of attachment to the parent, the infant progresses through four
distinct but overlapping stages: indiscriminate responding, differential crying, smiling,
and vocalization, visual-motor orientation, crying when the mother leaves the room,
approaching through locomotion, clinging, and exploring away from mother while
using her as a secure base.
Researchers have documented the effects of prolonged separation on infants in the
absence of high-quality parent substitutes. These effects include the inability to form
trusting, intimate interpersonal relationships, language impairment, and deficiency in
abstract thinking.
Spitz (1945) studied the effects of emotional deprivation on children raised in
foundling homes or institutions. She found that children developed normally if given
one-to-one attention by a mother substitute, but the long-term effects of separation
remain uncertain.
Infants at risk for severe attachment disorders include those who have experienced
physical or sexual abuse or neglect, parental alcoholism, mental illness, or
substance abuse, or the absence of a consistent primary caregiver.
SOCIAL DEVELOPMENT
Infants' social development is initially influenced by their reflexive behavior, and
eventually depends primarily on the interaction between them and their principal
caregivers.
Attachment
Human physical contact is extremely important for the attachment of parent and
child, which begins before birth and continues during the first year.
Studies demonstrate that father-child attachment occurs during the newborn period,
and that inexperienced first-time fathers are as capable as experienced fathers of
developing a close attachment with their infants. Fathers are also reported to have a
significant role in supporting the mother in the perinatal period.
When a grandmother becomes the primary caretaker, the infant may develop an
insecure attachment, which may result in psychosocial difficulties as the child grows
and may persist even into adulthood.
Attachment progresses during infancy, and the child assumes an increasingly
significant role in the family. Separation-individuation should occur as a harmonious,
parallel process with emotional attachment.
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In the first few weeks of life, babies cry for physiologic needs and for no apparent
reason, but later they cry for attention, fear, and frustration.
Parents may need guidance in consoling techniques, such as holding, swaddling,
massaging, caressing, rocking, walking, or stimulating sucking, because of the
variability of crying among infants.
Children with disinhibited social engagement disorder (DSED) and reactive
attachment disorder (RAD) of infancy or early childhood may manifest behaviors
such as not being cuddly with parents, failing to seek and respond to comfort when
distressed, minimal social and emotional reciprocity, and emotional deregulation.
Based on such findings, nurses should help families provide suitable caregiver
substitutes for the child, and emphasize the child's plasticity and resiliency in coping
to minimize the family's feelings of responsibility and guilt.
Separation anxiety develops between the ages of 4 and 8 months, when the infant
begins to have some awareness of self and mother as separate beings, and when
object permanence is developing, the infant begins to protest when the mother
leaves the room.
As infants demonstrate attachment to one person, they correspondingly exhibit less
friendliness to others. They begin to fear strangers and exhibit behaviors such as
clinging to the parent.
Language Development
The infant's first means of verbal communication is crying, which conveys a message
of urgency and signals displeasure, such as hunger. Crying also affects the
development of the parent-infant relationship, as it may evoke a negative response
or persuade parents to minister to the child's physical or emotional needs.
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Stimulation is as important for psychosocial growth as food is for physical growth.
Infants need to be played with, not merely allowed to play, and media other than
video-chatting should be discouraged in all children under the age of 18 months.
Table 10.2 lists play activities appropriate for the infant's developmental level in
terms of motor, language, and personal-social achievements.
TEMPERAMENT
The infant's temperament influences the type of interaction that occurs between the
child and parents and other family members.
Researchers agree that temperament has a strong biologic component, but they also
suggest that the environment, particularly the family, may modify temperament. The
nurse has an important role in helping the family understand temperament.
Some researchers speculate that maternal depression is linked to infant
temperament, and that a difficult infant temperament negatively affects the maternalinfant relationship. Fathers also experience postnatal depression when infants have
a difficult temperament.
Personal-Social Behavior
Personal-social behavior includes the child's responses to the environment and is
influenced by external stimuli. It provides the foundation for successful mastery of
skills.
By 6 months, infants are very personable and demonstrate their ability to control the
environment. They are also beginning to acquire fine and gross motor skills.
Infants understand simple discipline such as the word "no" and are sensitive to
emotional changes in others. They imitate actions and noises by 7 months.
From 11 months onward, children become increasingly independent, can feed
themselves, use a spoon and cup, and help with dressing. They can follow simple
directions and gladly perform for others.
Play
Infants' activity is primarily narcissistic and revolves around their own body. During
the first year, play becomes more sophisticated and interdependent, and infants
begin to laugh aloud, show preference for certain toys, and vocalize to an image in a
mirror.
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Several instruments can measure infant temperament, including the Revised Infant
Temperament Questionnaire, the Infant Behavior Questionnaire, and the Early
Infancy Temperament Questionnaire. Knowing the infant's temperament helps
nurses provide parents with background information and guide parents regarding
appropriate childrearing techniques.
Knowledge of the developmental sequence allows the nurse to assess normal
growth and minor or abnormal deviations, and helps parents gain realistic
expectations of their child's ability.
The developmental process during the first 12 months is complex. The table below
helps to organize and clarify the data already discussed and represents the average
monthly age at which various skills are attained.
Separation Anxiety and Stranger Fear
A stranger should talk softly, meet the child at eye level, maintain a safe distance
from the infant, and avoid sudden, intrusive gestures.
Parents may wonder whether they should encourage the child's clinging, dependent
behavior, but it is necessary for the child's optimum emotional development. Parents
can reassure the infant of their presence by talking to them when leaving the room,
using transitional objects, and talking on the telephone.
Limit Setting and Discipline
Infants' motor skills advance and mobility increases, and parents need to set safe
limits. Time-out is an effective disciplinary technique, but parents must recognize the
infant's cognitive and behavioral limitations and implement adequate protection from
hazards.
Developmental Screening in the First 3 Years
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As the infant gets older, parents may need assistance in providing limits that prevent
normal, disruptive behaviors from becoming problems.
Alternative Child Care Arrangements
For many parents, especially working mothers, locating safe and competent child
care facilities for the infant is a challenge.
Types of child care include in-home care (usually in the parents' or caregivers'
home), center-based care (usually in a day care center), and exchange babysitting.
Small family child day care homes typically provide care for up to six children.
Child center-based care is a licensed day care facility that provides care for six or
more children for six or more hours a day. Work-based group care is another option.
Parents should not discourage their infant from exploring, but rather provide safe
alternatives, put away dangerous household items, and give children consistent
discipline and nurturing. The fussy or irritable infant is a potential victim of traumatic
brain injury or shaken baby syndrome*.
Parents are concerned that too much attention can spoil a child. However, research
shows that the amount an infant cried during the first 3 months has no correlation
with the frequency of crying during the rest of the first year.
Spoiling is excessive self-centered and immature behavior, resulting from the failure
of parents to enforce consistent, age-appropriate limits. Indulging children does not
cause spoiling, but indulgence without clear expectations and limits can lead to
spoiling.
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The American Academy of Pediatrics' 2015 Red Book contains additional infection
control guidelines regarding day care hand hygiene, cleaning sleep equipment and
toys, food handling, preparation, and disposal, and handling, storage, and feeding of
human milk.
Thumb Sucking and Use of Pacifier
Sucking is the infant's chief pleasure and may not be satisfied by breastfeeding or
bottle-feeding. Parents may be overly concerned about the sucking of the fingers,
thumb, or pacifier and attempt to restrain this natural tendency.
Pacifier use in the early days after birth has gained considerable attention in the
scientific literature. However, recent research has shown no effects on pacifier use
and breastfeeding, and pacifier use should not replace actual feeding or suckling.
Parents should carefully evaluate a child care center's daily program, teacher
qualifications, nurturing qualities of caregivers, student-to-staff ratio, discipline policy,
emergency protocols, environmental safety precautions, provision of meals, sanitary
conditions, adequate indoor and outdoor space per child, and fee schedule before
allowing their child to attend.
Parents should check the center for health and safety features when selecting child
care, especially the number of unrelated children in the room. Proactive infection
control measures and education of staff are effective in reducing the incidence of
upper respiratory tract infections, diarrhea, and rotavirus.
Pacifier Use and Breastfeeding
Pacifier use is associated with an increased risk of otitis media in several studies, but
the American Academy of Pediatrics and American Academy of Family Physicians
recommend using a pacifier during the first 6 months of life.
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Teething is a physiologic process. Some children show minimal evidence of teething,
while others are irritable, have difficulty sleeping, mild temperature elevation, ear
rubbing, and decreased appetite for solid foods.
Teething pain is a result of inflammation, so giving the child a frozen teething ring or
an ice cube wrapped in a washcloth helps relieve the inflammation. Nonprescription
topical anesthetic ointments are available, but should only be used under the direct
advice and supervision of a health care provider.
NUTRITION
The choice of breastfeeding or bottle-feeding the newborn is highly individual. This
section is concerned with infant nutrition during the next 12 months.
Infants may be given solid foods when their digestive system is not ready to
completely absorb them, and drinks may be given in place of enriched.
Pacifier use is recommended for infants who are not directly breastfed and as soon
as breastfeeding is established in infants who are breastfed.
If the child uses a pacifier, stress safety considerations and caution parents against
altering a pacifier, thus making it more dangerous.
Infancy and early childhood are not the time to restrain nonnutritive sucking of the
fingers. However, persistent thumb sucking may be a sign of an emotional problem
between parent and child, or of boredom, isolation, and lack of stimulation.
Teething
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Skim or low-fat milk is unacceptable for breastfeeding mothers because it is deficient
in essential fatty acids and is too high in solute concentration. Fluoride
supplementation may be necessary.
Commercial iron-fortified formula is an acceptable alternative to breastfeeding for
infants less than 12 months of age. Unmodified whole cow's milk, low-fat cow's milk,
skim milk, other animal milks, and imitation milk drinks are not acceptable as a major
source of nutrition for infants.
Honey should be avoided in the first 12 months of life because of the risk of infant
botulism. Socializing the infant to food flavors of the family's culture is common.
Infant milk and solid foods may provide empty calories and contribute to
cardiovascular disease and obesity later in life, and place the infant at risk for iron
deficiency anemia, vitamin D deficiency, and rickets.
Health Canada has published and updated nutrition guidelines for healthy term
infants from birth to 6 months of age. These guidelines are available online.
The First 6 Months*
Human milk is the most desirable complete diet for the infant during the first 6
months of life. Breastfeeding is rarely contraindicated, but it is recommended to
consult with the health care provider before beginning.
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The Second 6 Months
During the second half of the first year, human milk or formula remains the primary
source of nutrition, and fluoride supplementation begins depending on the infant's
intake of fluoridated tap water when mixing commercial formula.
The infant's gastrointestinal tract has matured sufficiently to handle more complex
nutrients, and the infant's head control is well developed, allowing him to sit with
support and purposely turn the head away to communicate a lack of interest in food.
Many mothers find that breast-pumping when away from home and bottle-feeding
the infant the expressed milk with or without formula supplementation is successful.
Whether the infant is fed at home on a demand basis or every 3 to 4 hours, breast
milk must be expressed and stored in an appropriate airtight glass or plastic
container.
Mothers stop breastfeeding before 6 months because of concerns about infant
weight gain and adequate milk supply.
Infants are not ready for solid foods before 4 to 6 months of age. Their limited motor
abilities make it difficult to avoid feeding them and they instinctively suck when given
food.
Early introduction of solid food may reduce the frequency of breastfeeding or cause
eventual cessation of breastfeeding before 6 months of age. Caution parents
concerning the excessive use of juices and nonnutritive drinks during this period.
Bottled water is a safe alternative to tap water for mixing powdered or concentrated
formula. Fluoridated water is not necessary unless the local water source is low in
fluoride.
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Infants and toddlers should avoid low-calorie milk and foods, but certain types of
dietary fat are acceptable. Limit the amount of dietary fat in foods provided rather
than eliminating them altogether.
Commercially prepared baby foods are convenient and usually contain no added salt
or sugar, but they are relatively expensive. Parents are encouraged to offer their
child a variety of fruits, vegetables, and whole grains, including those known to be
naturally rich in iron.
Weaning
Weaning should be gradual and done one bottle-feeding or breastfeeding at a time.
If breastfeeding ends before 5 or 6 months of age, weaning should be done to a
bottle.
SLEEP AND ACTIVITY
Previous recommendations to avoid introducing potentially allergenic foods after 6 to
8 months of life have been questioned.
Selection and Introduction of Solid Foods
The choice of solid foods to introduce first is variable, but iron-fortified infant cereal is
generally introduced first because of its high iron content. Parents should avoid
cereal combinations when beginning a new grain.
Infant cereal may be mixed with formula or breast milk until whole milk is given. Fruit
juices can be mixed with the dry cereal after 6 months of age.
Parents can offer fruit juice as a rich source of vitamin C and as a substitute for milk
for one feeding a day. Avoid certain juices because they contain high amounts of
fructose and sorbitol and may cause abdominal pain, diarrhea, or bloating in some
children.
The order of introduction of other foods is arbitrary, but strained fruits are introduced
first, followed by vegetables, and finally meats. Only one solid food is introduced
every 5 to 7 days.
When introducing solids into the infant's diet, it is important to remember that the
majority of the infant's caloric needs come from the primary milk source (human or
formula). Also, keep in mind that smaller portions may help prevent overeating in
later life.
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Parents should avoid foods with concentrated sugar (sucrose) in the infant's diet and
should not bottle-feed or breastfeed during sleep. The practice of coating pacifiers
with honey or using commercially available hard-candy pacifiers is discouraged.
SAFETY PROMOTION AND INJURY PREVENTION
Injuries are a major cause of death during infancy. Suffocation, motor vehicle related injuries, and drowning are the three leading causes of accidental death injury
in infants.
Falls are the leading cause of nonfatal injuries among infants, and furniture such as
cribs, highchairs, baby walkers, changing tables, and bouncers can predispose to
such injuries. Constant vigilance, awareness, and supervision are essential as
children gain increased locomotor and manipulative skills.
Motor Vehicle Injuries
Infants usually sleep 9 to 11 hours a day, with three 1- to 2-hour naps during the day.
They usually take one or two naps per day by the end of the first year.
Most infants are naturally active and need no encouragement to be mobile. Devices
such as play yards, strollers, commercial swings, and walkers restrict movement and
prevent infants from exploring and developing necessary gross motor skills.
DENTAL HEALTH
Early dental hygiene begins with appropriate maternal dental health and counseling
regarding dietary intake for the promotion of optimal oral hygiene. Avoid propping the
milk bottle or giving the milk bottle in the bed.
Once the primary teeth erupt, parents should clean the teeth and gums with a damp
cloth. A brief oral health examination should be performed by 6 months of age, and
an established dental home should be established by 1 year of age.
Fluoride is needed for building caries-resistant teeth beginning at 6 months of age if
the infant does not receive water with adequate fluoride content.
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Infants and toddlers should ride in rear-facing car safety seats until they reach age 2
years or the weight recommended by the car seat manufacturer.
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One-third of all injuries to children occur in the home, so parents should be aware of
danger areas and implement safety devices and practices before their absence can
inflict injury on infants.
ANTICIPATORY GUIDANCE—CARE OF FAMILIES
Severe injuries and deaths have occurred from air bags deploying on impact in the
front passenger seat. Preterm infants should be placed in appropriate car seat
restraints as they would be placed in the car, and their heart rate and oxygen
saturation should be monitored.
Nurse’s Role in Injury Prevention
Injury prevention and parent education should be handled on a growth and
developmental basis, and a 4-month-old infant is at risk for the development of which
of the following?
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NCLEX REVIEW QUESTIONS
An infant's development of object permanence is represented by the infant's smile,
flexing and extending his arms and legs, looking for the mother when she walks out
of his view, and crying when the mother hands him to a babysitter.