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Peds notes INFANTS chapter 25  Children use diversion to cope with pain.  Cephalocaudal pattern: gross motor skills; baby learns to lift head before the baby will learn to roll over and sit.  Gross motor skills to fine motor skills. Infancy is the most rapid time Second most rapid time is adolescents There is a task in each stage according to Erikson Systems: body systems almost all of them are immature Do you think infants feel pain the same way that you do? They do feel it If you can get 90-95% oxygen saturation you’re in business! De-sats would be normal at first it might drop as low as 80% and if it does they’re in pain Do you think that children can have opioids? Yes, if you give an appropriate dose you can give them opioids How old do you have to be to have a PCA pump? As long as the child can make the connection the hurt is coming but the button that they should be able to have the PCA Listen to parents!!

Physical characteristics do not need to memorize exact numbers* Fontanel closure Posterior – 6-8 weeks CLOSES FIRST 2 months. Anterior at 12-18 months. If anterior is sunken in it could mean dehydration Bulging anterior means swelling could mean meningitis Increases ICP-decreased level of consciousness (not responding to stimuli) irritable, lethargic. Axillary temps. Need to know immediately if temp is high or low. Usually the anterior fontanel remains open until 12-18 months of age to accommodate rapid brain growth, However, the fontanel may close as early as 9 months of age, and this is not of concern in the infant with age appropriate growth and development. Physical characteristics Weight  6-8 pounds o 7.5 lbs o 3.4 kg

 doubles by 4months  triples by 12months Length  20 inches (20cm.)  grows 1 inch monthly by the first 6 months. Dentition  at 5-6 months teeth erupt (not uncommon to have a slight fever) 101.5 is FEVER o lower incisors first o cause increased saliva and drooling o enzyme released with teething causing mild diarrhea, facial skin irritation o slight fever may be associated; not high fever. Stanger anxiety  develops when attachment is in place o 6 months prefers mother  dads should talk to baby while in utero o 8 months protests loudly when mom leaves Nutrition  Whole milk to three years  Breast milk or formula to 1year 

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First solid foods begin at 4-6 months o rice cereal (zinc and hypoallergenic). Veggies (3-4 days to see if infant tolerates food), fruit, meat (chicken, turkey) Finger foods 8-9 months Cup at 10 months Not bottle propping Bottle weaning at 1 year

Psychological Aspects  Trust vs mistrust o Acquires a sense of trust o Cannot spoil-meet needs  Personality (temperament) Individuals nature. o Influences attachment o Easy, difficult, slow to warm up o Active, average, quiet Play (promoting Growth and Development Through play)  Solitary o He or she does not share with others or directly play with other infants  Onlooker

Assessing Newborns and Infants for Developmental Milestones • The nurse may ask the parent if the skill is present or the infant may demonstrate the skill during the interview. • The nurse may elicit the skill from the infant. • Screening tools may be used to assess development. – Denver II Developmental Screening Test • Does not diagnose – Prescreening Developmental Questionnaire (PDQ II) – Ages and Stages Questionnaire (ASQ) – Infant–Toddler Checklist for Language and Communication – Infant Development Inventory The following measurements: weight: 15 lb.; length: 26 in; and head circumference: 17 in are average measurements for a 6-month-old infant. The average weight for a 6-month-old infant is 15 lb., the average length is 25 to 27 in, and the average head circumference is 16.5 to 17.5 in. Respiratory System of the Infant Versus Adult • The nasal passages are narrower. • The trachea and chest wall are more compliant. • The bronchi and bronchioles are shorter and narrower. • The larynx is more funnel shaped. • The tongue is larger. • There are significantly fewer alveoli. Pc02 will go up Bicarb is low 

Average resp rate of a newborn is 30-60 breaths and decreases 20-30 first year of life

Maturation of the Cardiovascular System of the Infant in First Year of Life • The heart doubles in size. • The average pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1year-old. • Blood pressure steadily increases, from an average of 60/40 in the newborn to 100/50 in the 12-month-old. • The peripheral capillaries are closer to the surface of the skin, making the newborn and young infant more susceptible to heat loss. • Thermoregulation becomes more effective.

First Year of Life Changes • Eruption of teeth • Consistency and frequency of stools change over the first year of life • Acrocyanosis is normal in newborns and that they often experience mottling of the skin Warning Signs Indicating Problems with Sensory Development • Young infant does not respond to loud noises. • May have hearing issues. • Child does not focus on a near object. • Newborn is nearsighted, prefers to view objects at a distance of 20-38 cm (8-15 inches) • Infant does not start to make sounds or babble by 4 months of age. • Could be because they’re having a problem with hearing. • Infant does not turn to locate sound at age 4 months. • Infant crosses eyes most of the time at age 6 months. • Amblyopia • decreased vision in one or both eyes due to abnormal development of vision in infancy or childhood

BOOK POWERPOINTS Developmental Changes in the Newborn and Infant • Growth – Increase in physical size • Development – Sequential process by which infants and children gain various skills and functions • Maturation – Increase in functionality of various body systems or developmental skills Note: Newborn or neonatal period of infancy is birth till 28 days of age. Infancy is birth to 12 months

Assessing Newborns and Infants for Developmental Milestones • The nurse may ask the parent if the skill is present or the infant may demonstrate the skill during the interview. • The nurse may elicit the skill from the infant. • Screening tools may be used to assess development. – Denver II Developmental Screening Test – Prescreening Developmental Questionnaire (PDQ II) – Ages and Stages Questionnaire (ASQ) – Infant–Toddler Checklist for Language and Communication

– Infant Development Inventory Assessing Growth and Development of a Premature Infant • Use the infant’s adjusted age to determine expected outcomes. • Subtract the number of weeks that the infant was premature from the infant’s chronologic age. • Plot growth parameters and assess developmental milestones based on adjusted age. Infant Organ System Maturation • Neurologic system • Brain growth • Usually the anterior fontanel remains open until 12-18 months of age to accommodate rapid brain growth, However, the fontanel may close as early as 9 months of age, and this is not of concern in the infant with age appropriate growth and development. • Cardiovascular system • Respiratory system • Gastrointestinal (digestive) system • Teeth • Occasionally, an infant is born with one or two (termed natal teeth) or develops teeth in the first 28 days (neonatal). The presence of natal or neonatal teeth may be associated with other birth anomalies. • Majority of newborns do not have teeth and will not get them in the first month of life. • On average, the first primary teeth (deciduous teeth) erupt around ages of 6 and 8 months. • Lower central incisors are first to appear, followed by the upper central. • The average 12-month-old as four to 8 teeth. • Digestion • Trypsin is available in sufficient quantities for protein digestion after birth. • Amylase-needed for complex carbs and lipase for fat are both deficient in the infant and do not reach adult levels until about 5 months of age. • Functions of the liver remain immature until during the first year of live. • Stool • The newborns first stool (meconium) are the result of digestion of amniotic fluid swallowed in utero. They are dark green to black and sticky. • In the first few days of life the stool becomes yellowish to tan. • Renal system • Low specific gravity • Hematopoietic system • Immunologic system • Integumentary system • In utero, the infant is covered with vernix caseosa, which protects the developing infants skin. • Acrocyanosis and mottling of skin normal in newborns.

Newborn States of Consciousness 6 stages: neuro • Deep sleep: infant lies quietly without movement. • Light sleep: infant may move a little while sleeping and startle to noises. • Sleeping with eyes closed; rapid eye movements and irregular movements may be noticed. • Drowsiness: eyes may close; the infant may be dozing. • Quiet alert state: infant’s eyes are open wide and body is calm. • Active alert state: infant’s face and body move actively. • Crying: infant cries; body moves in disorganized fashion Newborn Primitive Reflexes (neuro) -primitive reflexes are subcortical and involve a whole-body response. These reflexes diminish over the first few months of life, given way to protective reflexes. (exception of baniksi) Present at birth: • Moro • Root • Suck • Asymmetric tonic neck • Plantar and palmar grasp • Step • Babinski • Disappears around 1 year. If it does not CNS issue. • The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out.

Respiratory System of the Infant Versus Adult • The nasal passages are narrower. • The trachea and chest wall are more compliant. • The bronchi and bronchioles are shorter and narrower. • The larynx is more funnel shaped. • The tongue is larger. • There are significantly fewer alveoli. • NOTE: these anatomic differences place the infant at higher risk for resp. compromise. The respiratory system does not reach adult levels of maturity until about 7 years of age. Lack of IgA in the mucosal lining also contributes to the frequency of infections that occur in infancy. • Respiratory system • The respiratory rate slows from an average of 60-30 breaths in a new born to about 20-30 in the 12-month-old. The newborn breaths irregularly, which periodic pauses. As the infant matures, the respiratory rate becomes more regular and rhythmic. Maturation of the Cardiovascular System of the Infant in First Year of Life • The heart doubles in size over the first year of life.

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The average pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1year-old. Blood pressure steadily increases, from an average of 60/40 in the newborn to 100/50 in the 12-month-old. The peripheral capillaries are closer to the surface of the skin, making the newborn and young infant more susceptible to heat loss. Thermoregulation becomes more effective.

First Year of Life Changes • Eruption of teeth • Consistency and frequency of stools change over the first year of life • Acrocyanosis is normal in newborns and that they often experience mottling of the skin Psychosocial Development • Erik Erikson theory • Crisis of infancy as trust versus mistrust (birth to one year) • Development of trust crucial in the first year of life. • Need to meet infant’s needs. Gross and Fine Motor Skills • Phenomenal increases • First 12 months • Development in this stage in a cephalocaudal fashion • From head to tail. Baby learns to lift head before baby learns to sit. • Fine motor development includes maturation of hand and finger use and develops in proximodistal fashion (from center to periphery). • feeding Warning Signs Indicating Problems With Sensory Development • Young infant does not respond to loud noises. • May have hearing issues. • Child does not focus on a near object. • Newborn is nearsighted, prefers to view objects at a distance of 20-38 cm (8-15 inches) • Infant does not start to make sounds or babble by 4 months of age. • Could be because they’re having a problem with hearing. • Infant does not turn to locate sound at age 4 months. • Infant crosses eyes most of the time at age 6 months. • Amblyopia • decreased vision in one or both eyes due to abnormal development of vision in infancy or childhood

Warning signs indicating problems with language development • Infant does not make sounds at 4 months of age. • Infant does not laugh or squeal by 6 months of age.

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Infant does not babble by 8 months of age; infant does not use single words with meaning at 12 months of age (mama, dada).

Social and Emotional Development of the Infant • Stranger anxiety – Indicates infant recognizes self as separate from others • Separation anxiety – Infant becomes distressed when parent leaves • Temperament – Ranges from low to moderately active, regular, and predictable, to highly active, more intense, and less adaptable • Cultural differences Nutritional Requirements • Essential for growth and development • Breast-feeding and bottle-feeding of infant formula are both acceptable • Needs related to the tremendous growth Exceptions to Recommended Breast-feeding • Infants with galactosemia • Maternal use of illicit drugs and a few prescription medications • Maternal untreated active tuberculosis • Maternal HIV infection in developed countries Breast-feeding • Advantages • Teach new mother proper techniques • New mothers should be assessed for pain upon breast-feeding • Iron conc. Is less in breastmilk and formula but the iron has increased bioavailability and is sufficient to meet the infants requirements for the first 4-6 months of life.

Bottle-Feeding • Proper preparation • Proper storage of formula • Care of bottles • Only formulas that are fortified with iron should be used

Nutritional Plan First Year of Life • Optimal feeding pattern • Infant feeding opportunity to establish good eating behaviors • Special formulas have been developed to meet the nutritional needs of infants with allergies or disorders • After 6 months

– Nutrients available in solid foods in addition to breast milk or formula – Introduce one new food every 4 to 7 days for identification of food allergies Role of Nurse • Promote early learning, safety, proper nutrition, healthy sleep and rest, healthy teeth and gums, and appropriate discipline techniques Common Developmental Concerns in Infancy • Colic • Inconsolable crying that lasts 3 hours or longer per day and for which there is no physical cause • Typically resolves by three months. • Cause is thought to be GI or neurological (probably system immaturity), temperament, or parenting style of the mother or father. • It may begin as early as 2 weeks of age, and healthy infants cry for a total of about 3 hours daily, 3-7days a week. • Reducing stimulation may decrease the length of crying. • Spitting up • Thumb sucking, pacifiers, security items • Pacifiers have been linked to otitis media. • Teething Anticipatory Guidance • Parents need tools to support their infant’s development in a safe fashion • Parents can promote growth and development of an infant through solitary play...