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TYPES OF CHILD DEVELOPMENT-CEPHALOCAUDAL, PROXIMODISTAL
Directional Trends Growth and development proceed in regular, related directions or
gradients and reflect the physical development and maturation of neuromuscular
functions (Fig. 3-1).
The first pattern is the cephalocaudal, or head-to-tail, direction. The head end of the
organism develops first and is large and complex, whereas the lower end is small and
simple and takes shape at a later period. The physical evidence of this trend is most
apparent during the period before birth, but it also applies to postnatal behavior
development. Infants achieve control of the heads before they have control of their
trunks and extremities, hold their backs erect before they stand, use their eyes before
their hands, and gain control of their hands before they have control of their feet.
Second, the proximodistal, or near-to-far, trend applies to the midline-to-peripheral
concept. A conspicuous illustration is the early embryonic development of limb buds,
which is followed by rudimentary fingers and toes. In infants, shoulder control precedes
mastery of the hands, the whole hand is used as a unit before the fingers can be
manipulated, and the central nervous system develops more rapidly than the peripheral
nervous system
The third trend, differentiation, describes development from simple operations to more
complex activities and functions, from broad, global patterns of behavior to more
specific, refined patterns. All areas of development (physical, cognitive, social, and
emotional) proceed in this direction.
WEIGHT AND LENGTH GROWING IN INFANTS
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SCHOOL CHILD GROW PER YEAR INCHES
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BMR BASAL METABOLIC RATE
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The rate of metabolism when the body is at rest (basal metabolic rate, or BMR)
demonstrates a distinctive change throughout childhood.
Highest in newborn infants, the BMR closely relates to the proportion of surface area to
body mass, which changes as the body increases in size.
In both sexes, the proportion decreases progressively to maturity.
The BMR is slightly higher in boys at all ages and further increases during pubescence
over that in girls.
The rate of metabolism determines the caloric requirements of the child. The basal
energy requirement of infants is about 108 kcal/kg of body weight and decreases to 40
to 45 kcal/kg at maturity. Water requirements throughout life remain at approximately 1.5
ml/calorie of energy expended. Children's energy needs vary considerably at different
ages and with changing circumstances.
The energy requirement to build tissue steadily decreases with age following the general
growth curve; however, energy needs vary with the individual child and may be
considerably higher. For short periods (e.g., during strenuous exercise) and more
prolonged periods (e.g., illness) the needs can be very high.
Each degree of fever increases the basal metabolism 10%, with a correspondingly
increased fluid requirement.
ERIKSON THEORY
The most widely accepted theory of personality development is that advanced by
Erikson (1963). Although built on Freudian theory, it is known as psychosocial
development and emphasizes a healthy personality as opposed to a pathologic
approach. Erikson also uses the biologic concepts of critical periods and epigenesis,
describing key conflicts or core problems that the individual strives to master during
critical periods in personality development. Successful completion or mastery of each of
these core conflicts is built on the satisfactory completion or mastery of the previous
stage.
Each psychosocial stage has two components—the favorable and the unfavorable
aspects of the core conflict—and progress to the next stage depends on resolution of
this conflict. No core conflict is ever mastered completely but remains a recurrent
problem throughout life. No life situation is ever secure. Each new situation presents the
conflict in a new form. For example, when children who have satisfactorily achieved a
sense of trust encounter a new experience (e.g., hospitalization), they must again
develop a sense of trust in those responsible for their care in order to master the
situation.
Erikson's life-span approach to personality development consists of eight stages;
however, only the first five relating to childhood are included here:
1. Trust versus mistrust (birth to 1 year old): The first and most important attribute to
develop for a healthy personality is basic trust. Establishment of basic trust dominates
the first year of life and describes all of the child's satisfying experiences at this age.
Corresponding to Freud's oral stage, it is a time of “getting” and “taking in” through all the
senses. It exists only in relation to something or someone; therefore, consistent, loving
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care by a mothering person is essential for development of trust. Mistrust develops when
trust-promoting experiences are deficient or lacking or when basic needs are
inconsistently or inadequately met. Although shreds of mistrust are sprinkled throughout
the personality, from a basic trust in parents stems trust in the world, other people, and
oneself. The result is faith and optimism.
2. Autonomy versus shame and doubt (1 to 3 years old): Corresponding to Freud's anal
stage, the problem of autonomy can be symbolized by the holding on and letting go of
the sphincter muscles. The development of autonomy during the toddler period is
centered on children's increasing ability to control their bodies, themselves, and their
environment. They want to do things for themselves using their newly acquired motor
skills of walking, climbing, and manipulating and their mental powers of selecting and
decision making. Much of their learning is acquired by imitating the activities and
behavior of others. Negative feelings of doubt and shame arise when children are made
to feel small and self-conscious, when their choices are disastrous, when others shame
them, or when they are forced to be dependent in areas in which they are capable of
assuming control. The favorable outcomes are self-control and willpower.
3. Initiative versus guilt (3 to 6 years old): The stage of initiative corresponds to Freud's
phallic stage and is characterized by vigorous, intrusive behavior; enterprise; and a
strong imagination. Children explore the physical world with all their senses and powers
(Fig. 3-4). They develop a conscience. No longer guided only by outsiders, they have an
inner voice that warns and threatens. Children sometimes undertake goals or activities
that are in conflict with those of parents or others, and being made to feel that their
activities or imaginings are bad produces a sense of guilt. Children must learn to retain a
sense of initiative without impinging on the rights and privileges of others. The lasting
outcomes are direction and purpose.
4. Industry versus inferiority (6 to 12 years old): The stage of industry is the latency
period of Freud. Having achieved the more crucial stages in personality development,
children are ready to be workers and producers. They want to engage in tasks and
activities that they can carry through to completion; they need and want real
achievement. Children learn to compete and cooperate with others, and they learn the
rules. It is a decisive period in their social relationships with others. Feelings of
inadequacy and inferiority may develop if too much is expected of them or if they believe
that they cannot measure up to the standards set for them by others. The ego quality
developed from a sense of industry is competence.
5. Identity versus role confusion (12 to 18 years old): Corresponding to Freud's genital
period, the development of identity is characterized by rapid and marked physical
changes. Previous trust in their bodies is shaken, and children become overly
preoccupied with the way they appear in the eyes of others compared with their own
self-concept. Adolescents struggle to fit the roles they have played and those they hope
to play with the current roles and fashions adopted by their peers, to integrate their
concepts and values with those of society, and to come to a decision regarding an
occupation. An inability to solve the core conflict results in role confusion. The outcome
of successful mastery is devotion and fidelity to others and to values and ideologies.
EGOCENTRISM?
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Preoperational (2 to 7 years old): The predominant characteristic of the preoperational
stage of intellectual development is egocentrism, which in this sense does not mean
selfishness or self centeredness but the inability to put oneself in the place of another
TYPES OF CHILD PLAYS
Social-affective play: Play begins with social-affective play, wherein infants take
pleasure in relationships with people. As adults talk, touch, nuzzle, and in various ways
elicit responses from an infant, the infant soon learns to provoke parental emotions and
responses with such behaviors as smiling, cooing, or initiating games and activities. The
type and intensity of the adult behavior with children vary among cultures.
Sense-pleasure play: Sense-pleasure play is a nonsocial stimulating experience that
originates from without. Objects in the environment—light and color, tastes and odors,
textures and consistencies —attract children's attention, stimulate their senses, and give
pleasure. Pleasurable experiences are derived from handling raw materials (water, sand,
food), body motion (swinging, bouncing, rocking), and other uses of senses and abilities
(smelling, humming) (Fig. 3-5). FIG 3-5 Children derive pleasure from handling raw
materials. (Paints in this picture are nontoxic.)
Skill play: After infants have developed the ability to grasp and manipulate, they
persistently demonstrate and exercise their newly acquired abilities through skill play,
repeating an action over and over again. The element of sense-pleasure play is often
evident in the practicing of a new ability, but all too frequently, the determination to
conquer the elusive skill produces pain and frustration (e.g., putting paper in and taking it
out of a toy car) (Fig. 3-6). After infants develop new skills to grasp and manipulate, they
begin to conquer new abilities, such as putting paper in a toy car and taking it out.
Unoccupied behavior: In unoccupied behavior, children are not playful but focusing their
attention momentarily on anything that strikes their interest. Children daydream, fiddle
with clothes or other objects, or walk aimlessly. This role differs from that of onlookers,
who actively observe the activity of others.
Dramatic, or pretend, play: One of the vital elements in children's process of
identification is dramatic play, also known as symbolic or pretend play. It begins in late
infancy (11 to 13 months) and is the predominant form of play in preschool children. After
children begin to invest situations and people with meanings and to attribute affective
significance to the world, they can pretend and fantasize almost anything. By acting out
events of daily life, children learn and practice the roles and identities modeled by the
members of their family and society. Children's toys, replicas of the tools of society,
provide a medium for learning about adult roles and activities that may be puzzling and
frustrating to them. Interacting with the world is one way children get to know it. The
simple, imitative, dramatic play of toddlers, such as using the telephone, driving a car, or
rocking a doll, evolves into more complex, sustained dramas of preschoolers, which
extend beyond common domestic matters to the wider aspects of the world and the
society, such as playing police officer, storekeeper, teacher, or nurse. Older children
work out elaborate themes, act out stories, and compose plays.
Games: Children in all cultures engage in games alone and with others. Solitary activity
involving games begins as very small children participate in repetitive activities and
progress to more complicated games that challenge their independent skills, such as
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puzzles, solitaire, and computer or video games. Very young children participate in
simple, imitative games such as pat-a-cake and peek-a-boo. Preschool children learn
and enjoy formal games, beginning with ritualistic, self-sustaining games, such as
ring-around-a-rosy and London Bridge. With the exception of some simple board games,
preschool children do not engage in competitive games. Preschoolers hate to lose and
try to cheat, want to change rules, or demand exceptions and opportunities to change
their moves. School-age children and adolescents enjoy competitive games, including
cards, checkers, and chess, and physically active games, such as baseball.
Onlooker play: During onlooker play, children watch what other children are doing but
make no attempt to enter into the play activity. There is an active interest in observing
the interaction of others but no movement toward participating. Watching an older sibling
bounce a ball is a common example of the onlooker role.
Solitary play: During solitary play, children play alone with toys different from those
used by other children in the same area. They enjoy the presence of other children but
make no effort to get close to or speak to them. Their interest is centered on their own
activity, which they pursue with no reference to the activities of the others.
Parallel play: During parallel activities, children play independently but among other
children. They play with toys similar to those the children around them are using but as
each child sees fit, neither influencing nor being influenced by the other children. Each
plays beside, but not with, other children (Fig. 3-7). There is no group association.
Parallel play is the characteristic play of toddlers, but it may also occur in other groups of
any age. Individuals who are involved in a creative craft with each person separately
working on an individual project are engaged in parallel play. FIG 3-7 Parallel play at the
beach.
Associative play: In associative play, children play together and are engaged in a
similar or even identical activity, but there is no organization, division of labor, leadership
assignment, or mutual goal. Children borrow and lend play materials, follow each other
with wagons and tricycles, and sometimes attempt to control who may or may not play in
the group. Each child acts according to his or her own wishes; there is no group goal
(Fig. 3-8). For example, two children play with dolls, borrowing articles of clothing from
each other and engaging in similar conversation, but neither directs the other's actions or
establishes rules regarding the limits of the play session. There is a great deal of
behavioral contagion: When one child initiates an activity, the entire group follows the
example. FIG 3-8 Associative play. 134
Cooperative play: Cooperative play is organized, and children play in a group with other
children (Fig. 3-9). They discuss and plan activities for the purposes of accomplishing an
end—to make something, attain a competitive goal, dramatize situations of adult or
group life, or play formal games. The group is loosely formed, but there is a marked
sense of belonging or not belonging. The goal and its attainment require organization of
activities, division of labor, and role playing. The leader–follower relationship is definitely
established, and the activity is controlled by one or two members who assign roles and
direct the activity of the others. The activity is organized to allow one child to supplement
another's function to complete the goal.
MAJOR COMPONENT OF PLAY
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Sensorimotor activity is a major component of play at all ages and is the predominant
form of play in infancy.
APPROPRIATE TOY FOR TODDLER
Toys that are small replicas of the culture and its tools help children assimilate into their
culture. Toys that require pushing, pulling, rolling, and manipulating teach them about
physical properties of the items and help develop muscles and coordination. Rules and
the basic elements of cooperation and organization are learned through board games.
Because they can be used in a variety of ways, raw materials with which children can
exercise their own creativity and imaginations are sometimes superior to ready-made
items. For example, building blocks can be used to construct a variety of structures,
count, and learn shapes and sizes.
MOST IMPORTANT INFLUENCE OF GROWTH
Genetics
TERATOGENS-SMOKING, ALCOHOL
Teratogens, agents that cause birth defects when present in the prenatal environment,
account for the majority of adverse intrauterine effects not attributable to genetic factors.
Types of teratogens include drugs (phenytoin [Dilantin], warfarin [Coumadin], isotretinoin
[Accutane]), chemicals (ethyl alcohol, cocaine, lead), infectious agents (rubella,
cytomegalovirus), physical agents (maternal ionizing radiation, hyperthermia), and
metabolic agents (maternal PKU). Many of these teratogenic exposures and the
resulting effects are completely preventable. For example, pregnant women can avoid
having a child with one of the fetal alcohol spectrum disorders by not ingesting alcohol
during pregnancy.
PAPULE
MACULE
VESICLE
HERPES ZOSTER LOCATION- GANGLIA OF SPINAL CORD
Posterior root ganglia
CHICKEN POX TREATMENT
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RINGWORM PEDICULOSIS SYMPTOMS
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Ringworm:
Pediculosis: Itching, caused by the crawling insect and insect saliva on the skin, is
usually the only symptom. Common sites of involvement are the occipital area, behind
the ears, and at the nape of the neck. Observation of the white eggs (nits) firmly
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attached to the hair shafts confirms the diagnosis. Because of their brief life span and
mobility, adult lice are difficult to locate.
WHICH INFECTION REQUIRE AIRBORNE PRECAUTION
measles, varicella (including disseminated zoster), and tuberculosis.
WHY GIVE ACYCLOVIR
The antiviral agent acyclovir (Zovirax) or valacyclovir may be used to treat varicella
infections in susceptible immunocompromised persons. It is effective in decreasing the
number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and
anorexia. Consider oral acyclovir or valacyclovir for immunocompromised children
without a history of varicella disease, newborns whose mother had varicella within 5
days before delivery or within 48 hours after delivery, and hospitalized preterm infants
with significant varicella exposure
VIT. A FOR RUBEOLA
Vitamin A supplementation Administer Vitamin A (World Heath Organization
recommendation) for children with acute illness: 200,000 International units for children
12 months old and older; 100,000 International units for children 6 through 11 months
old; 50,000 International units for infants younger than 6 months old
KOPLIK SPOT
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RUBELLA AND PREGNANCY
Rubella immunization is recommended for all children at 12 to 15 months old and at the
age of school entry or 4 to 6 years old or sooner, according to the routine
recommendations for the MMRV vaccine (American Academy of Pediatrics, 2015).
Increased emphasis should also be placed on vaccinating all unimmunized prepubertal
children and susceptible adolescents and adult women in the childbearing age group.
Because the live attenuated virus may cross the placenta and theoretically present a risk
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to the developing fetus, rubella vaccine is currently not given to any pregnant woman.
Although this is standard practice, current evidence from women who received the
vaccine while pregnant and delivered unaffected offspring indicates that the risk to the
fetus is negligible. In addition, there is no reported danger of administering rubella
vaccine to a child if the mother is pregnant. Postpubertal females without evidence of
rubella immunity should be immunized unless they are pregnant; they should be
counseled not to become pregnant for 28 days after receiving the rubella-containing
vaccine (American Academy of Pediatrics, 2015).
FONTANELS CLOSING TIME
Palpate the skull for patent sutures, fontanels, fractures, and swellings. Normally, the
posterior fontanel closes by 2 months old, and the anterior fontanel fuses between
12 and 18 months old. Early or late closure is noted, because either may be a sign of a
pathologic condition
WHEN SIT UNSUPPORTED
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TEETHING SCHEDULE
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WHEN INFANT START FEAR STRANGERS
6 months old; Recognizes parents; begins to fear strangers
WHEN START GIVE WHOLE MILK
whole milk is not recommended for infants younger than 12 months old
BEST AGE FOR SOLID FOOD
A survey of infant feeding practices found that about 20% of infants had consumed solid
foods before 4 months old despite recommendations that such foods not be introduced
until 4 to 6 months old
VITAMIN TO PREVENT NEURO DEFECTS
Folic Acid
VIT.D MOST COMMON ALLERGENS-EGG, COW MILK, WHEATH
PEDICULOSIS
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IRON SUPLEMENT ADMINISTARTION
SIDS PREVENTIONS
Nurses have a vital role in preventing SIDS by educating families about the risk of prone
sleeping position in infants from birth to 6 months old, the use of appropriate bedding
surfaces, the association with maternal smoking, and the dangers of co-sleeping on
non-infant surfaces with adults or other children. Additionally, nurses have an important
role in modeling behaviors for parents to foster practices that decrease the risk of SIDS,
including placing infants in a supine sleeping position in the hospital.
Research findings have important implications for practices that may reduce the risk of
SIDS, such as avoiding smoking during pregnancy and near the infant; using the
supine sleeping position; avoiding soft, moldable mattresses, blankets, and
pillows; avoiding bed sharing; breastfeeding; and avoiding overheating during
sleep.