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Growth and Development

Introduction

Prepared By

Dr. Muneeb Alzghool

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All children pass through predictable stages of

growth & development as they mature. Understanding the normal growth & development

is essential to establish a complete & effective nursing care plans for children.

Integrating the concepts of growth and development in patients’ care plans has the benefits of quality nursing care.

Children do not merely growth taller & heavier as they get older; maturing also involves growth in their ability to perform skills, to think, to relate to people, & to trust or have confidence in themselves.

Introduction

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Then, What is growth, and What is development?

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Growth

Used to denote an increase in physical size or a quantitative change

For Example, growth in weight is measured in pounds or kilograms. While height is measured

in inches or centimeters.

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Development Used to denote an increase in skills or ability to

function.

It is measured by observation, child recording (by parents’ description of a child progress), lab test (Denver test II).

E.g. child ability to pick up small objects such as pen, psychosexual development, cognitive development.

Maturity or maturation is synonym for development &

some consider it as the optimal increase in skills & development.

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Developmental Milestones

While growing, children demonstrate certain physical and mental skills.

These skills are called developmental

milestones.

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Principles of Growth and Development Growth and development are complex processes, begin

at conception and continue until death.

Growth and development proceed in an well defined sequence.

Different children pass through the predictable stages at different rates.

All body system do not develop at same rate. Development is cephalocaudal.

Development proceeds from proximal to distal body parts.

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Development proceeds from gross to refined skills.

Neonatal reflexes must be lost before development can proceed.

There is an optimal time for initiation of experience or

learning. A great deal of skills & behavior can be learned by

practice.

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Growth and development are complex processes begins at conception and continue until death.

An example of how the rate of growth changes is a comparison between that of the first year and later in life.

An infant double his birth weight at six month of age & triples by the end of the first year of life; & by the age of five, his weight would be ….. lb.

Another example is height that increases by 50% during the first year of life.

If this tremendous growth rate were to continue, the 5-yr-old child, would be 12 ft & 6 inches tall ( cm????)

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Different children pass through the predictable stages at different rates.

All stages of development have a range of time rather than a certain point at which they are usually accomplished.

Two children may pass through the motor sequence at such different rates, for example, that one begins walking at 9 mo, another only at 14 mo.

Both are developing normally. They are both following the predictable sequence; they are merely developing at different rates.

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All Body Systems Do Not Develop at the Same Rate

Certain body tissues mature more rapidly than others.

For example, neurologic tissue experiences its peak growth during the first year of life, whereas genital tissue grows little until puberty.

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Growth and Development Proceed in an Orderly Sequence

Growth occurs in only one sequence —for example height grows from smaller to larger.

Development also proceeds in a predictable order. For example, the majority of children sit before they creep, creep before they stand, stand before they walk, and walk before they run.

Occasionally, a child will skip a stage (or pass through it so quickly that the parents do not observe the stage).

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Development is Cephalocaudal Cephalo is a Greek word meaning “head”; caudal

means “tail.” Development proceeds from head to tail.

A newborn can lift only the head off the bed when he or she lies in a prone position.

By age 2 mo, the infant can lift the head and chest off the bed;

by 3 mo, the head, chest, and part of the abdomen; by 5 mo, the infant has enough control to turn over; by 9 mo, he or she can control the legs enough to

crawl; and by 1 yr, the child can stand upright and perhaps

walk. Motor development has proceeded in a cephalocaudal

order— from the head to the lower extremities.

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Development Proceeds from Proximal to Distal Body Parts

This principle is closely related to cephalocaudal development.

It can best be illustrated by tracing the progress of upper extremity development.

A newborn makes little use of the arms or hands. Any movement, except to put a thumb in the mouth

By age 3 or 4 mo, the infant has enough arm control to support the upper body weight on the forearms, and the infant can coordinate the hand to scoop up objects.

By 10 mo, the infant can coordinate the arm and thumb and index fingers sufficiently well to use a pincer like grasp.

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Cephalocaudal Vs Proximal to Distal

Cephalocaudal Proximal to distal

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Development Proceeds from Gross to Refined Skills

This principle parallels the preceding one. Once the child is able to control distal body parts such as fingers, he or she is able to perform fine motor skills.

E.g. (a 3-yr-old colors best with a large crayon; a 12-yrold can write with a fine pen).

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There is an Optimum Time for Initiation of Experiences or Learning

A child cannot learn tasks until his or her nervous system is mature enough to allow that particular learning.

Children who are not given the opportunity to learn developmental tasks at the appropriate or “target” times for that task may have more difficulty than the usual child learning the task later on. (e.g. toilets training)

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Neonatal Reflexes Must be Lost Before Development Can Proceed.

An infant cannot grasp with skill until the grasp reflex has faded nor stand steadily until the walking reflex has faded.

Neonatal reflexes are replaced by purposeful movements

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A Great Deal of Skill and Behavior is Learned by Practice.

Infants practice over and over taking a first step before they accomplish this securely.

If children fall behind in growth and development because of illness, they are capable of “catch-up” growth to bring them equal again with their age group.

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Factors that Affect Growth and

Development

Genetics

Intelligence

Gender

Temperament

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Genetics

Although each child is unique, certain gender -related characteristics will influence growth and development .

In addition to physical characteristics such as eye color and height potential, inheritance determines other characteristics such as learning style and temperament .

An individual may also inherit a genetic abnormality, which may result in disability or illness at birth or later in life

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Gender On average, girls are born lighter and shorter than

boys.

Boys tend to keep this height and weight advantage until prepuberty, at which time girls surge ahead because they begin their puberty growth spurt 6 months to 1 year earlier than boys.

By the end of puberty(14 to 16 years), boys again tend to be taller and heavier than girls.

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Health

A child who inherits a genetically transmitted disease may not grow as rapidly or develop as fully as a healthy child.

Depending on the type of illness and the therapy or care available for the disease.

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Intelligence Children with high intelligence do not generally

grow faster physically than other Children but they do tend to advance faster in skills.

Because they spends time with books or mental games rather than with games that develop motor skills.

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Temperament

Is the usual reaction pattern of an individual, or an individual 's characteristic manner of thinking, behaving, or reacting to stimuli in the environment

Unlike cognitive or moral development, temperament is not developed by stages but is an inborn characteristics set at birth.

Understanding that children are not all alike will help the parents to deal with their children

Some adapt quickly to new situations and others adapt slowly, and some react intensely and some passively.

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Reaction Patterns

Each child's pattern is made up of a combination of these individual elements. Distractibility Attention Span and Persistence Threshold of Response Mood Quality Activity Level Rhythmicity Approach Adaptability Intensity of Reaction

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Activity level Level of activity among children differs widely.

Some babies are constantly on the go and rarely quiet.

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Rhythmicity

A child who has rhythmicity manifests a regular rhythm in physiologic functions.

Even as infants, such children tend to wake up at the same time each morning, are hungry at regular 4-hour periods, nap the same time every day, and have a bowel movement at the same time every day. They are predictable and easy to care for because their parents learn early on what to expect from them.

On the other end of the scale are infants with an irregular rhythmicity. They rarely awaken at the same time 2 days in row. They may go a long time without eating one day and the next day appear hungry almost immediately after a feeding. Such children may be more difficult to care for because it is difficult to plan a schedule for them.

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Approach

Approach refers to a child's response on initial contact with a new stimulus. Some children approach new situations in an unruffled manner. They smile and “talk” to strangers and accept a first feeding or a new food without spit ting up or fussing. They explore new toys without apprehension.

Other children demonstrate withdrawal rather than approach to new situations. They cry at the sight of strangers, new toys, and new foods; they fuss the first time they are placed in a bathtub. They are difficult to take on vacation or to meet a new childcare provider because they react so fear fully to new situations.

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Adaptability

Adaptability is the ability to change one's reaction to stimuli over time.

Infants who are adaptable can change their first reaction to a situation without exhibiting extreme distress.

The first time such children are placed in a bathtub they might protest loudly, for example, but by the third time they sit splashing happily.

This is in contrast to infants who cry for months whenever they are put into a bathtub or who cannot seem to accustom themselves to a new bed, , or new caregiver.

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Intensity of Reaction

Some children react to situations with their whole being. They cry loudly, thrash their arms, and begin temper tantrums when their diapers are wet , when they are hungry, and when their parents leave them.

Others rarely demonstrate such over symptoms of anger or have a mild or low-intensity reaction to stress.

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Distractibility

Children who are easily distracted or who can easily shift their attention to a new situation (distractibility) can be easily managed. As infants, they can be diverted and calmed by a pacifier

Other children cannot be distracted; their parents may describe them as stubborn, willful, or unwilling to compromise because they persistently return to an activity or refuse to adapt or change.

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Attention Span and Persistence Attention span is the ability to remain interested

in a project or activity.

Some play by themselves with one toy for an hour; others spend no more than 1 or 2 minutes with each toy.

The degree of persistence also varies.

Some infants keep trying to perform an activity even when they fail time after time; others stop trying after one unsuccessful attempt

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Threshold of Response

The threshold of response is the intensity level of stimulation that is necessary to evoke a reaction.

Children with a low threshold need little stimulation; those with a high threshold need intense stimulation before they become upset over a situation.

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Mood Quality

A child who is always happy and laughing has a positive mood quality. Obviously, this can make a major difference in the parents' enjoyment of a child .

Parents are bound to spend more time with him or her than parents whose child has a negative mood quality.

Growth and development are complex processes, begin at conception and continue until death.

Growth and development proceed in an well defined sequence.

Different children pass through the predictable stages at different rates.

All body system do not develop at same rate. Development is cephalocaudal.

Development proceeds from proximal to distal body parts

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Genetics Intelligence Gender Temperament

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Distractibility Attention Span and Persistence Threshold of Response Mood Quality Activity Level Rhythmicity Approach Adaptability Intensity of Reaction

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Categories of Temperament

The Difficult Child Slow-to-Warm-Up Child The Easy Child

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The Difficult Child

Children are “difficult” if they are irregular in habits, have a negative mood quality, and withdraw rather than approach new situations.

Only about 10% of children fall into this category.

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Slow-to-Warm-Up Child

Children fall into this category if they are overall fairly inactive; respond only mildly and adapt slowly to new situations, and have a general negative mood.

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The Easy Child

Children are rated as “easy to care for” if they have a predictable rhythmicity, approach and adapt to new situations readily, have a mild to moderate intensity of reaction, and have an overall positive mood quality.

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Environment

The environment surrounding the child would affect their growth in some way.

For example, a child may receive inadequate nutrition because of the family’s low socioeconomic status; would grow lighter than other child with good nutrition

Ineffective child-parents’ relationship make a parent lack of skills or not give a child enough attention. Loved children thrive better than unloved one. or a child could have a chronic illness.

All could directly alter their growth rate

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Evidence of Growth

1. Physiological growth: (V/S, Body grow).

2. Behaviors growth: (movement, sitting).

3. Cognitive growth.

4. Emotional Growth.

5. Social growth.

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Phase Stage From To One Embryo Conception 8 G/W

Fetus 8 G/W Delivery Two Newborn Delivery 28 days

Infant 28 days One year Toddler One year Three years Pre-school age Three years Six year

Three School age Six year 12 years Adolescent 13 years 20 years

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Theories of Growth and Development

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Fetal DevelopmentGrowth and development/

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Stages of Fetal Development Fetal growth and development is typically

divided into three periods:

1. Pre-embryonic: first 2 weeks, beginning with fertilization

2. Embryonic (weeks 3 through 8).

3. Fetal (from week 8 through birth).

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Stages of Fetal Development Ovum

From ovulation to fertilization Zygote

From fertilization to implantation Embryo

From implantation to 5–8 weeks Fetus

From 5–8 weeks until term Conceptus

Developing embryo or fetus and placental structures throughout pregnancy

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Fertilization: The Beginning of Pregnancy.

Fertilization: Union of an ovum and a spermatozoon. This usually

occurs in the outer third of a fallopian tube, the ampullar portion

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Implantation

Once fertilization is complete, the zygote migrates over the next 3 to 4 days toward the body of the uterus

The first cleavage occurs at about 24 hours By the time the zygote reaches the body of the uterus,

it consists of 16 to 50 cells (morula). The morula continues to multiply as it floats free in the

uterine cavity for 3 or 4 more days. Blastocyst: is Large cells tend to collect at the

periphery of the ball, leaving a fluid space surrounding an inner cell mass.

The cells in the outer ring are known as trophoblast cells. They are the part of the structure that will later form the placenta and membranes.

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Extra-embryonic Membranes

The embryo reaches the uterus on day 6. It penetrates the endometrial lining & initiates

membrane formation. Amnion: Encloses embryo Chorion: Forms from the trophoblast, interacts

with uterine tissue to form the placenta.

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Mohammad Aljaiussy 54

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Mohammad Aljaiussy 56

Milestones of Fetal Growth and Development End of 4th G/W End of 8th G/W End of 12th G/W (First Trimester) End of 16th G/W End of 20th G/W End of 24th G/W (Second Trimester) End of 28th G/W End of 32nd G/W End of 36th G/W End of 40th G/W (Third Trimester)

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End of 4th G/W

Length: 0.75 to 1 cm Weight: 400 mg The spinal cord is

formed and fused at the midpoint.

Lateral wings that will form the body are folded forward to fuse at the midline.

Head folds forward and becomes prominent, representing about one third of the entire structure.

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End of 4th G/W

The back is bent so that the head almost touches the tip of the tail.

The rudimentary heart appears as a prominent bulge on the anterior surface.

Arms and legs are budlike structures. Rudimentary eyes, ears, and nose are

discernible.

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End of 8th G/W

Length: 2.5 cm (1 in) Weight: 20 g Organogenesis is complete. The heart, with a septum and valves, is

beating rhythmically. Facial features are definitely discernible. Arms and legs have developed.

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End of 8th G/W

External genitalia are present, but sex is not distinguishable by simple observation.

The primitive tail is regressing. Abdomen appears large because the fetal

intestine is growing rapidly. Sonogram shows a gestational sac, diagnostic

of pregnancy

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End of 12th Gestational Week (First Trimester)

Length: 7 to 8 cm Weight: 45 g Nail beds are forming on fingers and toes Spontaneous movements are possible, although

they are usually too faint to be felt by the mother. Some reflexes, such as the Babaniski reflex, are

present.

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End of 12th Gestational Week (First Trimester)

Bone ossification centers are forming. Tooth buds are present. Sex is distinguishable by outward appearance. Kidney secretion has begun, although urine may not

yet be evident in amniotic fluid. Heart beat is audible through Doppler technology.

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End of 16th Gestational Week

Length: 10 to 17 cm Weight: 55 to 120 g Fetal heart sounds are audible with an ordinary

stethoscope. Lanugo (the fine, downy hair on the back and arms of

newborns, which apparently serves as a source of insulation for body heat) is well formed.

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End of 16th Gestational Week

Liver and pancreas are functioning. Fetus actively swallows amniotic fluid, demonstrating

an intact but uncoordinated swallowing reflex; urine is present in amniotic fluid.

Sex can be determined by ultrasonography.

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End of 20th Gestational Week

Length: 25 cm Weight: 223 g Spontaneous fetal movements can be sensed by the

mother. Antibody production is possible. Hair forms, extending to include eyebrows and hair on

the head. Meconium is present in the upper intestine.

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End of 20th Gestational Week

Brown fat, a special fat that will aid in temperature regulation at birth, begins to be formed behind the kidneys, sternum, and posterior neck.

Vernix caseosa, which serves as a protective skin covering during intrauterine life, begins to form.

Definite sleeping and activity patterns are distinguishable( the fetus has developed biorhythms that will guide sleep/wake patterns throughout life).

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End of 24th Gestational Week (Second Trimester)

Length: 28 to 36 cm Weight: 550 g Passive antibody transfer from mother to fetus

probably begins as early as the 20th week of gestation, certainly by the 24th week.

Infants born before antibody transfer has taken place have no natural immunity and need more than the usual protection against infectious disease in the newborn period until the infant's own store of immunoglobulin can build up.

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End of 24th Gestational Week (Second Trimester)

Meconuim is present as far as the rectum. Active production of lung surfactant begins. Eyebrows and eyelashes are well defined. Eyelids, previously fused since the 12th week, are now

open. Pupils are capable of reacting to light. Hearing can be demonstrated by response to sudden

sound.

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End of 28th Gestational Week

Length: 35 to 38 cm Weight: 1,200 g Lung alveoli begin to mature, and surfactant can be

demonstrated in amniotic fluid. Testes begin to descend into the scrotal sac from the

lower abdominal cavity. The blood vessels of the retina are thin and extremely

susceptible to damage from high oxygen concentrations (an important consideration when caring for preterm infants who need oxygen).

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End of 32nd Gestational Week

Length: 38 to 43 cm Weight: 1,600 g Subcutaneous fat begins to be deposited (the former

stringy, “little old man” appearance is lost). Active Moro reflex is present. Birth position (vertex or breech) may be assumed. Iron stores, which provide iron for the time during which

the neonate ingests only milk after birth, are beginning to be developed.

Fingernails grow to reach the end of finger tips.

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End of 36th Gestational Week

Length: 42 to 48 cm Weight: 1,800 to 2,700 g (5 to 6 lb) Body stores of glycogen, iron, carbohydrate, and

calcium are deposited. Sole of the foot has only one or two crisscross creases,

compared with the full crisscross pattern that will be evident at term.

Amount of lanugo begins to diminish. Most babies turn into a vertex or head-down

presentation during this month.

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End of 40th Gestational Week (Third Trimester)

Length: 48 to 52 cm (crown to rump, 35 to 37 cm) Weight: 3,000 g (7 to 7.5 lb) Fetus kicks actively, hard enough to cause the mother

considerable discomfort. Fetal hemoglobin begins its conversion to adult

hemoglobin. The conversion is so rapid that, at birth, about 20% of hemoglobin is adult in character.

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End of 40th Gestational Week (Third Trimester)

Vernix caseosa is fully formed. Finger nails extend over the fingertips. Creases on the soles of the feet cover at least two

thirds of the surface. In primiparas: the fetus often sinks into the birth

canal during the last 2 weeks, giving the mother a feeling that the load she is carrying is less. This event , termed lightening

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Fetal Movement and Fetal Heart Rate Fetal Movement Fetal movement that can be felt by the mother

(quickening) begins at approximately 18 to 20 weeks of pregnancy and peaks at 28 to 38 weeks. A healthy fetus moves with a degree of consistency, or at least 10 times a day.

In contrast, a fetus not receiving enough nutrients because of placental insufficiency has greatly decreased movements. Based on this, asking the mother to observe and record the number of movements the fetus makes daily offers a gross assessment of fetal well -being.

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Fetal Movement and Fetal Heart Rate

Fetal Heart Rate: Fetal hearts beat at 120 to 160 beats per minute

throughout pregnancy. Fetal heart sounds can be heard and counted as

early as the 10th to 11th week of pregnancy by the use of an ultrasonic Doppler technique

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The Infancy Period

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Infant or the Infancy Period:

Is the period that last from 28 days of life through the first year of life.

Heart rate: 100-120 Weight: Triple by 1 year Height Grows by 50%

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Physical Growth: Weight

Weight: Most infants double their birth weight at 4 to

6 months and triple it by 1year. First 6 months, average a weight gain of 2 lb

per month. The second 6 months, weight gain is

approximately 1lb per month. The average 1-year -old boy weighs 10 kg;

the average girl weighs 9.5 kg

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Physical Growth: Length

Increases in length during the first year by 50%. 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.

At the end of the first year, the child's legs may still appear disproportionately short & curved.

Length increases 2.5 cm each month in the first 6 months of life.

And increases 1.5 cm each month in the second 6 months of life.

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Physical Growth: Head Circumference Head circumference increases rapidly during the infant

period, reflecting rapid brain growth. By the end of the first year , the brain has already reached two thirds of its adult size.

Children head circumference increases 2.5 cm each month in the first 6 months of life.

And increase 0.5 cm each months in the second 6 month of the first year.

Some infants' heads appear asymmetric until the second half of the first year. This may occur from always being placed in one sleeping position,

Suggest to parents that they place the infant on the back to sleep and prone when playing. This head distortion gradually corrects itself as the child sleeps less and spends more time with the head in an erect position

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Physical Growth: Body Proportion

The mandible becomes more prominent as bone grows.

By the end of an infant period, the lower jaw is 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.

The abdomen remains protuberant until the child has been walking well.

Lengthening of the lower extremities during the last 6 months of infancy readies the child for walking

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Body Systems In the cardiovascular system, heart rate slows from 120

to 160 b/pm to 100 to 120 b/pm by the end of the first year.

The heart continues to occupy a little over half the width of the chest. That the heart is becoming more efficient is shown by the 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 and another at 5-6 month. The first is due to the life of a red cell is 4 months, but new cells are not yet being produced in adequate replacement numbers.

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The second one is because hemoglobin in an infant becomes totally converted from fetal to adult hemoglobin at 5 to 6 months of age.

And because infant’s iron stores established in uterus is totally used.

The respiratory rate of an infant slows from 30 to 60 breaths/min to 20 to 30 breaths/min by the end of the first year.

Because the lumen (tubal cavity) of the respiratory tract remains small and mucous production by the tract is still inefficient , upper respiratory infections occur readily and tend to be more severe than in adults.

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The gastrointestinal tract is mature gradually during the infant year . Although the ability to digest protein is present and effective at birth, the amount of amylase, necessary for the digestion of complex carbohydrates, is deficient until approximately the third month.

The liver of an infant remains immature. The kidneys remain immature and not as

efficient at eliminating body wastes as in the adult

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Until age 3 or 4 months, an extrusion reflex prevents some infants from eating effectively.

The endocrine system remains particularly immature.,

An infant 's immune system becomes functional by at least 2 months of age; an infant can actively produce both IgG and IgM antibodies by 1 year .

•The levels of other immunoglobulins ( IgA, IgE, and IgD) are not plentiful until preschool age, the reason infants continue to need protection from infection (immunization).

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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 .

Extra cellular fluid accounts for approximately 35% of an infant 's body weight , with intra cellular fluid accounting for approximately 40%

•This proportional difference increases an infant's susceptibility to dehydration from illnesses such as diarrhea, because loss of extra cellular fluid could result in loss of over a third of an infant's body fluid.

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Teeth The first baby tooth usually erupts at age 6 months,

followed by a new one monthly, lower erupts first (6-10 mo) then the upper (8-12mo)

teething patterns can vary greatly among children.

Some newborns may be born with teeth (called natal teeth) or have teeth erupt in the first 4 weeks of life (called neonatal teeth) .

If they are loosely attached, they should be removed before they loosen spontaneously and are aspirated by an infant.

Deciduous teeth (temporary or baby teeth) are essential for protecting the growth of the dental arch.

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Motor Development Assessing motor development includes: •Gross motor development(ability to

accomplish large body movements) such as sitting, walking.

•Fine motor development, which is measured by observing or testing ability to coordinate hand movements such as grasping

an object.

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Gross Motor Development Infant is observed in four positions: ventral

suspension. prone. sitting and standing. Ventral Suspension Position:

Ventral suspension refers to an infant 's appearance when held in mid air on a horizontal plane, supported by a hand under the abdomen.

In this position, the newborn allows the head to hang down with little effort at control

A 1-month-old child lifts the head momentarily, then drops it again. He or she may flex the elbows, extend the hips, and flex the knees.

Two-month-old child renhold their heads in the same plane as the rest of their body, a major advance in muscle control

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A 3-month-old child lifts and maintains the head well above the plane of the rest of the body in ventral suspension.

At 6 to 9 months, an infant also demonstrates a parachute reaction from a ventral suspension position. When infants are suddenly lowered toward an examining table from ventral suspension, the arms extend as if to protect themselves from falling.

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Prone Position By 1 month of age, infants lift their heads and turn them

easily to the side. They still tend to keep their knees tucked under the abdomen as they did as a newborn.

Two-month-old infant scan raise their heads and maintain the position, but they cannot raise their chests 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.

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Four-month-old children lift their chests off the bed and look around actively, turning their heads from side to side. They can turn from front to back. The first time, this tends to occur as an extension of lifting the chest combined with the neck-righting reflex, which begins at this age. When an infant turns the head to the side, the shoulders, trunk, and pelvis turn in that direction, too.

A 5-month-old child rests weight on the forearms when prone. He or she can turn completely over, front to back and back to front

At 6 months, infants rest their weight on their hands with extended arms. They can raise their chests and the upper part of their abdomens off the table.

By 9 months, the child can creep from the prone position.

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Sitting Position A 1-month-old child has gross head lag as in the

first days of life. In a sitting position, the back appears rounded and an infant demonstrates only momentary head control .

The 2-month-old child can hold his or her head fairly steady when sitting up. An infant at this age still has head lag when pulled to a sitting position.

A 3-month-old child has only slight 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.

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A 5-month-old infant can be seen to straighten his or her back when held or propped in a sitting position.

By 6 months, children sit momentarily without support. A 7-month-old child sits alone, but only when the hands

are held forward for balance.

An 8-month-old child can sit securely without additional support

At 9 months, infants sit so steadily they can lean forward and regain their balance.

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Standing Position At 1 month of age, an infant's knees and hips flex

rather than support more than momentary weight. A 2-month-old child, when held in a standing

position, holds his or her head up with the same show of support as in a sitting position.

At 3 months, infants begin to try to support part of their weight . The stepping reflex begins to fade.

At 4 months, infants make an attempt to sustain their weight actively on their legs. They are successful at doing this because the stepping reflex has faded.

A 5-month-old child continues the ability to sustain a portion of his or her weight.

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By 6 months, infants support nearly their full weight when in a standing position.

A 7-month-old child bounces with enjoyment in a standing position.

A 9-month-old child can stand holding onto a coffee table if he or she is placed in that position. Some 9-month-old children can pull up to that position.

Ten-month-old children 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 as yet .

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At around 11 months, a child learns to ―cruise or move about the crib or room by holding onto objects such as the crib rails, chairs, walls, and low tables

At 12 months, a child stands alone at least momentarily. Some parents expect their child to walk at this time and are disappointed to see him or her not moving but merely standing.

A child has until about 22 months of age to walk and still be within the normal limit

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Fine Motor Development One-month-old infants still have a strong grasp reflex,

and they hold their hands in fists so tightly, it is difficult to extend the fingers.

A 2-month-old childwill hold an object for a few minutes before dropping it. The hands are held open, not closed in fists.

At 3 months, infants reach for attractive objects in front of them. Their grasp is unpracticed, however , so they usually miss them. Grasp is meaningful.

By 4 months, infants bring their hands together and pull at their clothes.

Thumb opposition (ability to bring the thumb and fingers together) is beginning. An infant is limited to handling large objects .

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Five-month-old children can accept objects that are handed to them and grasp with the whole hand. They can reach and pick up objects without the object being offered and often play with their toes as objects.

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 for the same hand. They can hold a spoon and start to feed themselves (with much spilling).

A 7-month-old child can transfer a toy from one hand to the other. He or she holds a first object when a second one is offered.

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By 8 months, random reaching and ineffective grasping have disappeared as a result of advanced eye–hand coordination.

At 10 months child is able to bring the thumb and first finger together in a pincer grasp. This enables a child to pick up small objects such as crumbs or pieces of cereal from a highchair tray. The infant uses one finger to point to objects.

At 12 months, infants can draw a semi straight line with a crayon. 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.

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Language Development A child begins to make small, cooing (dovelike)

sounds by the end of the first month. The 2-month-old child differentiates a cry. For

example, caregivers can distinguish a cry that means ―hungry from one that means ―wet or from one that means ―lonely."

A 3-month-old child will squeal with pleasure. This is an important step in development because it makes a baby even more fun to be with.

By 4 months, infants are very ― talkative,‖ cooing, babbling, and gurgling when spoken to. They definitely laugh out loud.

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By 5 months, an infant says some simple vowel sounds ( for example, ―goo-goo and ―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 at 7 months. They can imitate vowel sounds well ( for example, ―oh-oh, ―ah-ah, and ―oo-oo).

By 9 months, an infant usually speaks a first word: ―da-da or ―ba-ba. Occasionally a mother may need reassurance that ―da-da‖ for daddy is an easier syllable to pronounce than ―ma-ma for mommy.

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By 10 months, an infant masters another word such as ―bye-bye‖ or ―no.

At 12 months, infants can generally say two words besides ―ma-ma and ―da-da; they use those two words with meaning.

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Play Because 1-month-olds can fix their eyes on an object,

they are interested in watching a mobile over their crib or playpen. Also spend a great deal of time watching their parent 's face, appearing to enjoy this activity so much a face may become their favorite ― toy. Hearing is a second sense that is a source of pleasure for the child in early infancy.

Two-month-old infants will hold light , small rattles for a short period of time but then drop them. They are very at tuned to mobiles or cradle strung across their crib. They continue to spend a great deal of time just watching the people around them.

Three-month-old children can handle small blocks or small rattle

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Four -month-old children 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 is so exciting it may serve as a ―toy for the entire month.

Five-month-old infants are ready for a variety of objects to handle, these objects should be small enough an infant can lift them with one hand, yet big enough the baby 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. Because they are starting to teeth, infants enjoy a teething ring to chew on at this time

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Because 7-month-old children can transfer toys, they are interested in items. 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 children are sensitive to differences in texture. They enjoy having toys that have different feels to them, such as fur, 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 .

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 reach and remove.

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At 11 months, children have learned to cruise or walk along low tables by holding on. They often find this so absorbing 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 objects such as blocks into a cardboard box. As soon as they can walk, they will be interested in pull toys. A lot of time may be spent listening to someone saying nursery rhymes or listening to music.

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Development of Senses Vision

One-month-old infants watch an object in the midline of their vision. They follow it a short distance, but not across the midline as yet. They study or regard a human face with a fixed stare.

Two-month-old infants focus well ( from about age 6 weeks) and follow objects with the eyes (although still not past the midline) .

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).

Four-month-old infants recognize familiar objects, such as a frequently seen bottle, rattle, or toy animal. They follow their parents' movements with their eyes eagerly.

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At 6 months, infants are capable of organized depth perception. This increases the accuracy of their reach for objects as they begin to perceive distances accurately. Up until 6 months of age, infants may experience difficulty in establishing eye coordination. After this age, however , an infant whose eyes still ―cross‖ should be examined by a physician.

Seven-month-old children pat their image in a mirror. Their depth perception has matured to the extent they can perform such tasks as transfer ring toys from hand to hand.

By 10 months, an infant looks under a towel or around a corner for a concealed object (beginning of object permanence) . If the child's movement is restricted in any way, move the position of the mobile from time to time. Photos of family members brought from home or pictures drawn by older brothers or sisters can be posted near an infant 's crib.

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Hearing •Hearing is demonstrated by the 1-month-oldchild

who quiets momentarily at a distinctive sound such as a bell or a squeaky rubber toy.

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-oldinfants turn their heads 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.

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Six-month-old have progressed to being able to locate sounds made above them.

By 10 months, infants can recognize their name and listen acutely when spoken to.

By 12 months, infants can easily locate sound in any direction and turn toward it . A vocabulary of two words plus ―ma-ma and ―da-da also demonstrates an infant can hear. Tape recordings of maternal heart sounds can be soothing to very young infants

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Touch An infant needs to be touched so he or she experiences

skin-to-skin contact . Clothes should feel comfortable and soft rather than rough;

diapers should be dry rather than wet .

Taste Infants demonstrate that they have an acute sense of taste

by turning away from or spitting out a taste they do not enjoy.

Smell Infants can smell accurately within 1 or 2 hours after birth. They appear to enjoy pleasant odors and learn early in life to

identify the familiar smell of breast milk.

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Emotional Development 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.

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.

By 3 months, infants demonstrate increased social awareness by readily smiling at the sight of a parent 's face .Three-month-old infants laugh out loud at the sight of a funny face

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By 4 months, when a person who has been playing with and entertaining an infant leaves, an infant is likely to cry to show he or she enjoyed the interaction. 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.

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.

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Seven-month-old infants begin to show obvious fear of strangers. They may cry when taken from their parent , at tempt to cling to him or her , and reach out to be taken back.

Fear of strangers reaches its heightduring the eighth month, so much so this phenomenon is of ten termed eighth-month anxiety, or stranger anxiety. An infant at the height of this phase will not go willingly from a parent 's arms to a nurse's.

Nine-month-old infants are very aware of changes in tone of voice. They will 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 again when approached. They like to play interactive nursery rhymes and rhythm games and ―dance‖ with others. They like being at the table for meals and joining in family activities

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The Nursing Role in Health Promotion of an Infant and Family

Childproofing: When infants begin teething at 5 to 6 months, they chew on any

object within reach to lessen gum-line pain. Remind parents to check for possible sources of lead paint, Accidents are a leading cause of death in children from 1 month through 24 years of age.

Aspiration Prevention: Aspiration is a potential threat to infants throughout the first

year .. Educate parents who feed their infant formula not to prop bottles.

Other instances of aspiration occur because parents under estimate their infant 's ability to grasp and place objects in their mouth.

When solid foods are introduced, encourage parents to offer small pieces of hot dogs or grapes, not large chunks.

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Fall Prevention Car Safety: use of car seats

Safety with Siblings: As infants become more fun to play with at about 3 months, older brothers and sisters grow more interested in interacting with them. You may need to remind parents that children under 5 years of age, as a group, are not responsible enough or knowledgeable enough about infants to be left unattended with them.

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Teaching, Infant Safety Teaching, infant safety, is defined as instruction on

safety during the first year of life .Some important activities involved when implementing this intervention include instructing the parent /caregiver in the following at:

0 to 3 months •Using car seat •Put ting infant to sleep on back •Maintaining all equipment such as swings, strollers in

proper working condition •Checking temperature of formula and bath water •Keeping pets at a safe distance •Never shaking, tossing, or swinging infant in air

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•4 to 6 months Avoiding use of walkers or jumpers Never leaving infant unattended in

tub Using a safe highchair Feeding only soft or mashed foods Removing small objects from infant 's

reach

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7 to 9 months Avoiding sources of lead poisoning Providing barriers to potentially dangerous areas Supervising infant's activity at all times

10 to 12 months Providing protection from glass furniture, sharp

edges, and appliances Storing all cleaning supplies out of infant's reach Using childproof latches on cupboards Preventing infant's access to upper-story windows,

balconies, and stairs Selecting toys according to manufacturer's age

recommendations Ensuring barriers to pools, hot tubs, ponds, and all

containers with liquid

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Promoting Nutritional Health of an Infant Teaching, Infant Nutrition 0 to 3 months

Feeding only breast milk or formula for first year Always holding infant when feeding and never propping

bottle when feeding Limiting water intake to 1½2 oz to 1 oz at a time Avoiding use of honey or corn syrup Al lowing non-nutritive sucking

4 to 6 months Introducing solid foods without added salt or sugar and

iron-fortified cereal , one food at a time Avoiding use of juice or sweetened drinks Feeding from a spoon only

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7 to 9 months Introducing finger foods and cup when infant is able to sit

up Having infant join family at mealtimes Al lowing self-feeding, with observation to prevent choking Offering fluids after solids Introducing limited amounts of diluted juice in a cup Avoiding sugary desserts and soda

10 to 12 months Offering 3 meals and heal thy snacks Beginning to wean from bottle and beginning table foods Avoiding fruit drinks and flavored milk Allowing infant to feed self with spoon

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Parental Concerns and Problems Related to Normal Infant Development

Teething Most infants have little difficulty with teething,

but some appear very distressed. Generally, the gums are sore and tender

before a new tooth breaks the surface. As soon as the tooth is through, the tenderness passes.

Because of this pain, infants can be resistant to chewing for a day or two and be slightly irritable, possibly because they are a little hungry from not eating as much as usual.

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High fever , seizures, vomiting or diarrhea, and earache are never normal signs of teething.

Acetaminophen, 10 to 15 mg/kg every 4 hours, up to four times a day, may be used for teething discomfort Always encourage parents to check with their infant's health care provider before giving any over -the-counter drug this way.

Teething rings that can be placed in the refrigerator provide soothing coolness against the tender gums.

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Thumb Sucking Parents can be assured that thumb

sucking is normal and does not deform the jaw line as long as it stops by school age.

Use of Pacifiers A major drawback of pacifiers is the problem of

cleanliness. They tend to fall on the floor or sidewalk and are then put back into an infant's mouth.

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If not well constructed, they may come apart and be aspirated.

Hanging a pacifier on a string around an infant's neck could cause strangulation.

Parents should attempt to wean a child from a pacifier any time after 3 months of age and certainly during the time the sucking reflex is fading at 6 to 9 months.

Weaning after this age is difficult because a pacifier becomes a comfort mechanism, like a warm blanket or fuzzy toy to which a child may cling.

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Head Banging •Some infants rhythmically bang their heads

against the bars of a crib for a period of time before falling asleep.

•Head banging in this limited fashion—beginning during the second half of the first year of life and continuing through to the preschool period, associated with naptime or bedtime, and lasting under 15 minutes—can be considered normal.

•Advise parents to pad the rails of cribs so infants cannot hurt themselves, and reassure them this is a normal mechanism for relief of tension in children of this age

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Sleep Problems Sleep problems develop in early infancy

because of colic or because an otherwise healthy infant takes longer than usual to adjust to sleeping through the night.

Breast -fed babies tend to wake more often than those who are formula-fed because breast milk is more easily digested, so infants become hungry sooner.

In late infancy, the problem of waking at night and remaining awake for an hour or more becomes common.

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Suggestions for eliminating or at least coping with night waking are:- (1) delay bed time by 1 hour (2) shorten an afternoon sleep period (3) do not respond immediately to

infants at night so they can have time to fall back to sleep on their own

(4) provide soft toys or music to allow infants to play quietly alone during

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Constipation Breast -fed infants are rarely constipated because their

stools tend to be loose. Constipation may occur in formula-fed infants if their diet is

deficient in fluid. This can be corrected simply with the addition of more fluid.

Some parents misinterpret the normal pushing movements of a newborn to be constipation.

Loose Stools Stools of breast-fed infants are generally softer than those

of formula-fed infants. If a mother takes a laxative while breast-feeding, an infant 's stools may be very loose.

An infant who is formula-fed can have loose stools if the formula is not diluted properly. Occasionally, loose stools may begin with the introduction of solid food, such as fruit .

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Colic Colic is paroxysmal abdominal pain that. The cause of

colic is unclear. It may occur in susceptible infants from overfeeding or from swallowing too much air while feeding.

Formula-fed babies are more likely to have colic than breast-fed babies, possibly because they swallow more air while drinking.

Spitting Up Almost all infants spit up, although formula-fed babies

appear to do it more than breast-fed babies. Reassure parents that spitting up decreases in amount

as the baby becomes better at coordinating his or her swallowing and digestive processes( the cardiac sphincter matures) .

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Diaper Dermatitis Frequent diaper changing applying A & D or Desitin ointment exposing the diaper area to air may

relieve the problem.

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Baby-Bottle Syndrome Putting an infant to bed with a bottle can result in

aspiration or decay of all the upper teeth and the lower posterior teeth Decay occurs because while an infant sleeps, liquid from the propped bottle continuously soaks the upper front teeth and lower back teeth ( the lower front teeth are protected by the tongue).

is most serious when the bottle is filled with sugar water, formula, milk, or fruit juice. The carbohydrate in these solutions ferments to organic acids that demineralize the tooth enamel until it decays.

To prevent this problem, advise parents never to put their baby to bed with a bottle.

If parents insist a bottle is necessary to allow a baby to fall asleep, encourage them to fill it with water and use a nipple with a smaller hole to prevent the baby from receiving a large amount of fluid.

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If the baby refuses to drink anything but milk, the parents might dilute the milk with water more and more each night until the bottle is down to water only.

Obesity in Infants Obesity in infants is defined as a weight greater than

the 90th to 95th percentile on a standardized height/weight chart.

Overfeeding in infancy often occurs because parents were taught to eat everything on their plate, and they continue to instill this concept in their children.

Another way to help prevent obesity is to add a source of fiber , such as whole-grain cereal and raw fruit, to an infant's diet .