Health Promotion of the Infant: Birth to 1 Year

Chapter 18: Key Terms and Development Concepts

• Anthropometric measurements (AN-thro-po-MET-rik MEZH-er-ments): Measurements of the human body, such as weight, height (length), and head circumference.
• Chromosomes (KROH-muh-sohmz): Threadlike structures within cells that carry genetic information.
• Failure to thrive (FTT) (FAYL-yuhr too THRYEV): A condition where an infant fails to gain weight and grow according to standardized charts.
• Genetics (je-NET-iks): The study of genes, chromosomes, and genotypes and how they are expressed.
• Genomics (je-NOH-miks): The study of the structure and function of genes and how genetics influence complex diseases.
• Hereditary (huh-RED-ih-tair-ee): Characteristics transmitted from parents to offspring.
• Immunizations (IM-yoo-nih-ZAY-shunz): The process of inducing active immunity to prevent infectious diseases.
• Myelination (MYE-uh-lih-NAY-shun): The growth of a myelin sheath around nerve fibers.
• Separation anxiety (SEP-uh-RAY-shun ang-ZYE-uh-tee): Anxiety expressed when a child is separated from their parents; typically starts at $8$ to $10$ months.
• Stranger anxiety (STRAYN-jer ang-ZYE-uh-tee): Fussy or crying behavior when interacting with unknown individuals; typically occurs around $6$ months.
• Thermoregulation (THER-moh-REG-yoo-LAY-shun): The physiological process of maintaining a stable core body temperature.

Genetic Influences and Stages of Childhood

• The Nine Stages of Childhood:     1. Premature infants: Born before $36$ weeks' gestation.     2. Newborn infants: Birth to $28$ or $30$ days.     3. Early infancy: $1$ to $6$ months.     4. Older infancy: $6$ months to $1$ year.     5. Toddler: $1$ to $3$ years.     6. Preschooler: $3$ to $5$ years.     7. Early school-aged: $6$ to $10$ years.     8. Late school-aged: $11$ to $13$ years.     9. Adolescent: $13$ to $18$ years.

• Inheritance Patterns:     * Carriers: Individuals with one defective gene and one healthy gene. If one parent is a carrier, there is a $25\%$ chance of the child having the disease, a $50\%$ chance of being a carrier, and a $25\%$ chance of being unaffected.     * Autosomal Dominant: Only one defective gene is required for the condition (e.g., osteogenesis imperfecta, neurofibromatosis, night blindness).     * Autosomal Recessive: Both parents must pass the defective gene (e.g., sickle cell disease, phenylketonuria (PKU), albinism).     * Sex-Linked Disorders: Carried on the X chromosome and passed by women (e.g., hemophilia, glucose-6-phosphate dehydrogenase (G6PD), color blindness).

• Down Syndrome (Trisomy 21): A genetic condition involving an extra chromosome $21$. Associated with intellectual disabilities, congenital heart disease, sleep apnea, thyroid disease, and acute lymphocytic leukemia (ALL). Requires a multidisciplinary team (cardiologist, speech therapist, OT, PT, etc.).

The Newborn Period: Physical Systems and Transition

• Transition to Extrauterine Life: Refers to the first $24$ hours of life. Key changes include moving from placental to independent circulation, closure of fetal ducts, and establishing independent breathing.     * Tactile Stimulation: Drying the skin, rubbing the back/trunk, or flicking the soles of the feet can stimulate breathing.
• Cardiovascular System:     * Assessment: Check for cyanosis, mottling, edema, and clubbing. Auscultate heart sounds (aortic, pulmonic, Erb’s point, tricuspid, mitral). Compare femoral and brachial pulses.     * Incidence: Innocent heart murmurs are found in up to $50\%$ of infants.
• Thermoregulation: Essential for survival and blood glucose stability.     * Normal range: $36^{\circ}\text{C}$ ($96.8^{\circ}\text{F}$) to $37.5^{\circ}\text{C}$ ($99.5^{\circ}\text{F}$).     * Teaching: Swaddle in blankets; wear a soft hat; dress in one layer more than adults.
• Respiratory System:     * Anatomy: Large head, short neck, large tongue, and narrow nasal passages (obligate nose breathers). The cricoid ring is the narrowest part of the airway.     * Assessment: Monitor for retractions, nasal flaring, head bobbing, and shoulder rolling.
• Gastrointestinal System: Reduced gut flora and gastric enzymes. Breastfeeding introduces flora.     * Fluid Needs: $125$ to $150\,mL/kg/day$.     * Introduction of Solids: Start at $6$ months with iron-fortified cereal.     * Stool Patterns (Table 18.1):         * Meconium: Thick, sticky, black/green; passed in first few days.         * Transitional: Green/brown to yellow/brown; occurs around day $3$.         * Breast Milk Stool: Orange-yellow, soft/even; appears after day $4$.         * Formula Stool: Color/odor depends on formula; soft consistency.
• Genitourinary System: Bladder capacity is $15$ to $20\,mL$. Immature kidneys cannot concentrate urine or electrolytes well.
• Endocrine System: Influenced by maternal hormones.     * Witch's milk: Secretion from newborn nipples.     * Pseudomenstruation: Blood-colored vaginal secretion in newborn girls.     * Hypoglycemia: Risk for stressed infants; requires feeding every $3$ hours or gavage if too sick to suck.
• Sensory Organs: Smell is well developed (can distinguish mother's milk). Vision is immature; en face position is encouraged.

Infant Nutrition and Feeding Guidelines

• Feeding Evolution:     * Breast/formula exclusively until $6$ months ($8$ to $12$ feedings per day initially).     * Food Introduction Order: Iron-fortified cereal $\rightarrow$ Green vegetables $\rightarrow$ Yellow/orange vegetables $\rightarrow$ Pureed fruits $\rightarrow$ Meats/egg yolks ($10$ months).     * Cow's Milk: No cow's milk until $12$ months to avoid intestinal microbleeds and "milk anemia." Whole milk should be used from ages $1$ to $2$; skip skim milk until after age $2$.
• Breastfeeding Benefits (Table 18.2):     * Infant: Faster gastric emptying, defense factors (IgA, lactoferrin), reduced obesity, SIDS, and OM (otitis media) risk.     * Mother: Weight loss, uterine involution, lower risk of breast/ovarian cancer and type $2$ diabetes.
• Breast Milk Storage:     * Room temperature: $6$ to $8$ hours.     * Refrigerator: $4$ to $5$ days.     * Insulated bag: $24$ hours.     * Freezer (refrigerator unit): $2$ weeks.     * Deep freezer: $3$ to $6$ months.
• Formula Calculation: Based on Table 18.3.     * $0$ to $30$ days: $100$ to $110\,Kcal/kg/day$.     * $1$ to $4$ months: $90$ to $100\,Kcal/kg/day$.     * $5$ months to $5$ years: $70$ to $90\,Kcal/kg/day$.     * Safety Stat: Never microwave formula (creates "hot spots"). Use sterile water for mixing in first few months.

Physical Growth and Developmental Milestones

• Physical Growth:     * Weight: Triples by $12$ months; increases by $0.68\,kg$ ($1.5\,lb$)/month (first $6$ months) then $0.34\,kg$ ($0.75\,lb$)/month (next $6$ months).     * Length: Doubles by $12$ months ($2.54\,cm$ or $1\,in$ per month).     * Head Circumference (OFC): Average is $43.18\,cm$ ($17\,in$) at $6$ months and $45.72\,cm$ ($18\,in$) at $12$ months.     * Fontanels: Posterior closes at $2$ to $3$ months; Anterior at $12$ to $18$ months.
• Dentition (Fig. 18.4): Eruption begins at $5$ to $7$ months (central incisors first). Six to eight teeth by end of year $1$.
• Gross Motor Milestones (Box 18.2):     * $3$ months: Holds head up.     * $5$ to $6$ months: Rolls over (prone to supine).     * $7$ months: Sits leaning forward.     * $8$ months: Sits unsupported.     * $9$ months: Pulls to stand.     * $10$ months: Cruises.     * $12$ months: Stands alone; independent walking ($9$ to $12$ months).
• Fine Motor Milestones (Box 18.3):     * $3$ months: Identifies hands.     * $4$ months: Grasps rattle voluntarily.     * $6$ months: Transfers objects hand-to-hand.     * $7.5$ to $8.5$ months: Pincer grasp mastered.     * $9$ months: Drinks from sippy cup; uses finger and thumb (prehension).     * $12$ months: Builds two-block tower; nests two items.

Developmental Theories and Communication

• Developmental Theorists (Table 18.4):     * Erik Erikson (Psychosocial): Crisis is "Trust vs. Mistrust." predictability in care establishes trust.     * Sigmund Freud (Psychosexual): "Oral Stage" (birth to $18$ months). Satisfaction via sucking and biting.     * Jean Piaget (Cognitive): "Sensorimotor Stage."         * $0$ to $1$ month: Reflexes.         * $4$ to $8$ months: Focus on objects.         * $8$ to $12$ months: Object permanence (searching for hidden items).
• Communication Milestones:     * $1$ to $2$ months: Cooing.     * $2$ to $4$ months: Laughing.     * $3$ to $4$ months: Consonant sounds.     * $6$ months: Imitative sounds.     * $12$ months: Says one to two words with meaning (e.g., "Da-Da", "No").

Sleeping Patterns and Safety

• Sleep Requirements: Newborns ($22$ to $23$ hours/day); Older infants ($16$ hours/day, including two naps).
• SIDS Prevention:     * Back-to-sleep position ONLY.     * Crib safety: Firm mattress, no pillows, bumpers, blankets, or stuffed animals. No waterbeds.     * No co-sleeping or electric blankets.     * Pacifiers: One-piece plastic models preferred (Fig. 18.6).

Health Promotion and Anticipatory Guidance (Box 18.4)

• Sun Safety: No sunscreen under $6$ months (skin absorbs chemicals). Use wide-brimmed hats and hoods.
• Car Seat Safety: Center of back seat, rear-facing. Never leave unattended in cars (heat deaths).
• Crib Selection: Slat space should be no wider than $2\,3/8$ inches ($6\,cm$). No drop-gate sides. Lockable wheels.
• Toy Safety: Solitary play. Items with strings/cords longer than $6$ inches are strangulation risks. Avoid toys with small buttons.
• Well-Child Schedule (Table 18.5):     * $2$ Months: Hep B, Rotavirus, DTaP, Hib, PCV, Polio.     * $4$ Months: Rotavirus, DTaP, Hib, PCV, Polio.     * $6$ Months: Hep B, Rotavirus, DTaP, Hib, PCV, Polio, Influenza, COVID-19.     * $12$ Months: DTaP, Hep A, Hib, PCV, Varicella, MMR, RSV.

Screening, Injury Prevention, and Hospital Safety

• Otitis Media (OM): Middle ear infection. Prevent by breastfeeding and feeding in an upright position.
• Poisoning: Storage in childproof containers. National Poison Control: $1\text{-}800\text{-}222\text{-}1222$.
• Burn Prevention: Water heaters set no higher than $48.8^{\circ}\text{C}$ ($120^{\circ}\text{F}$).
• Hospital Checklist for Safety (Table 18.7):     * ID bands must match child and parent; never remove for any reason.     * Every bed needs airway equipment (manual resuscitator and $3$ mask sizes: newborn, pediatric, adult).     * Crib rails up to maximum height at all times.
• Pediatric Treatment Room Checklist (Table 18.6):     * Stocked with distraction tools (bubbles, toys).     * Ready crash cart, suction, oxygen source, and cardiac monitoring.     * "Mummy wrap" blankets for restraint.

Disorders of the Infant (Table 18.8)

• SUIDS/SIDS: Peaks between $1$ and $4$ months. 2017: $1,400$ SIDS deaths, $3,600$ SUID.     * Signs: Bloody mucus, cyanosis, petechiae on pleura/pericardia.
• Dehydration:     * Mild: Hard to evaluate; stable vitals.     * Moderate: $10\%$ weight loss, elevated HR, decreased urine output (UOP).     * Severe: Delayed capillary refill, absent tears, sunken fontanels, dry membranes; lower BP is a late sign.     * Intervention: Isotonic IV bolus ($20\,mL/kg$) or oral rehydration solution (ORS).
• Colic: Persistent crying ($3$ hours/day, $3$ days/week, $3$ weeks). No organic cause typically found. Resolves by $6$ months.
• Failure to Thrive (FTT): Weight falls below $5\text{th}$ percentile.     * Organic: Underlying medical condition (heart, GI, anemia).     * Nonorganic: Psychosocial factors (poverty, depression).

Questions and Discussion

• Critical Thinking (Danielle Case): A $9$-month-old with no immunizations in an area with a pertussis epidemic. Consequences include high risk for life-threatening illness. Nursing concerns include public health risks and parental education strategies.
• Review Questions:     1. Tripling birth weight happens at approximately $12$ months.     2. Moderate dehydration symptoms include decreased urine output.     3. Maternal iron stores are typically depleted by $6$ months.     4. Erikson's theory focuses on sense of Trust.     5. Accuracy in meds is best ensured by double-checking with a second nurse.     6. Appropriate food to introduce first is iron-fortified cereal.