THE FIRST YEAR OF LIFE

1. THE FIRST YEAR OF LIFE

2. Physical Changes • Weight Gain: • 1st 6 mos: 1.5 #/motil 5 mos; • Wt doubles by 6 mo; average 16# • Triples by 1 yr; average 21.5# • Height: • Increases 1”/mo 1st 6 mo • Average 25.5” at 6 mo • By 1 yr. ↑d by ~50%; average 29”

3. Physical Changes • Head Circumference: • Imp. determinant of brain growth • ↑s 2 cm/mo from birth to 3 mos; 1 cm/mo from 4-6 mos; .5 cm from 6-12 mos. • Average 17” at 6 mos and 18” at 12 mos • Increased by 33% by 1 yr. • Chest Circumference: • Almost = to HC by end of 1st yr • Heart wt double by 1 yr; width is 55% of chest

4. Neuro Reflexes: Some disappear and new ones appear (p. 247, Table 8-4, 9th ed. , p. 264 Table 7-4 & p. 414, Box 10-1, 10th ed.) • Vision: (p. 414, Box 10-2, 10th ed.) • Binocularity starts at 6 wks; well developed by 4 mos • Depth perception 7-9 months • Infant has visual preference for human face ; by 6 mos distinguish bet. familiar and strange faces; follows developmental sequence

5. Hearing: progressive myelination of auditory pathway; goes from generalized response to specific responses of locating sound • Moro or startle reflex to loud noise as neonate • By one yr. knows several words and their meaning

6. Respiratory system: abdominal breathing • Predisposed to acute resp. problems d/t physiology (small airways, ↓ IgA and mucous production → ↑risk of infection, short & straight eustachian tube allows infection to go from pharnyx to ear, etc.) • Heart rate slows; rhythm often that of sinus arrhythmia; ↑s w/inspiration and ↓s w/ expiration

7. Cardiovascular: • Fetal hemoglobin present 1st 5 mostil adult hgb replaces it • Fetal hgb results in ↓d life span of RBCs so ↓d # which results in physiologic anemia. BUT • Maternal stores are present til 5-6 mos so not a problem. • Hgb levels often do ↓ about 6 mos and Fe supplement becomes necessary as erythropoiesis is stimulated. (fortified rice cereal is great resource)

8. Digestive system: at first solid foods are passed incompletely broken down in feces • Breast milk or formula recommended by AAP for first year of life. Less food allergies, and better use of calories and nutrients • By end of yr. can eat 3 meals/day, evening bottle or breastfeeding, and have 1-2 BMs daily (although still prone to diarrhea, vomiting and dehydration w/any gastric irritation)

9. Immune system: receives maternal IgG at birth that covers 1st 3 mos and begins to synthesize IgG; 40% of adult levels by 1year • IgM adult levels by 9-12 mos • IgA, IgD, IgE level not until early childhood

10. Fine Motor • Palmar Grasp, using whole hand, progresses to the Pincer Grasp (9 months), using thumb & index finger • 6 mos: hold bottle, grasp feet, feed selves cracker • 7 mos: transfer objects from 1 hand to other; bang objects together • 10 mos: let go of object on purpose

11. Gross Motor • Maturation in: posture, head balance, sitting, creeping, standing, walking • Head control: 4-6 mos well established; no head lag by 6 mos or refer • Rolling over: abd to back 5 mo; back to abd 6 mos; parachute reflex 7 mos • Sitting: sits alone at 7 mos w/hands support; 8 mos unsupported; 10 mos prone to sitting

12. Gross Motor (cont) • Locomotion: cephalocaudal pattern • Begins by pushing w/arms and propelling selves ackwards • Crawling to creeping at 9 mos • 11 mos walk holding onto furniture • 1 yr walk w/1 hand held • If does not pull to stand by 11-12 mos refer for eval

13. Psychosocial Development • Sense of Trust vs Mistrust • Trust of self, of others, and of the world – provides foundation for all next phases • Trust that their feeding, comfort, stimulation and caring needs will be met • Mistrust results from too much or too little frustration • Consistency of care is essential

14. Trust vs Mistrust • Two oral/social stages • First is food intake; newborn can tolerate little frustration; then learn other ways to interact thru grasping; tactile stimulation extremely imp. in child/caregiver relations • Second is biting, more active & aggressive interaction w/environment; relief from teething and sense of power or control

15. Cognitive DevelopmentPiaget (Table 12-1, p. 473, 9th ed., Table10-1 p. 422 10th ed.) • Sensorimotor phase: Birth to 24 mos • Separation – learn to separate selves from other objects in environment • Object permanence – objects that leave the visual field still exist (9-10mos) • Use of symbols or mental representation (i.e. bye-bye means Daddy goes to work) • Begin to imitate, play, and show affect

16. Body Image: time of exploration of body parts; hands, feet, fingers are all play things & objects of pleasure • Sexual identity: as explore body are capable of genital self stimulation; male erections are common • Social development: importance of human physical contact cannot be stressed enough

17. Attachment • Primary caregiver can be the mother, father, grandparent, etc. • Absence of a quality caregiver, esp 1st 3 yrs. of life can →severe mental & physical retardation. • Reactive Attachment Disorder (RAD): maladaptive or absent attachment bet. infant & parent. Signs occur b/4 5 yo.: not cuddly w/parent, no eye contact, poor impulse control, destructive to self and others→no conscience

18. Separation Anxiety: Between 4-8 mos. as begins to have awareness of self & parent as separate → object permanence makes aware parent can be absent→anxiety • Approach at eye level, talk softly, don’t smile big, allow to stay on parent’s lap & keep familiar object w/them • Stranger Fear: between 6-8 mos. show fear of strangers

19. Stages of Separation Anxiety (p. 965-967, Hockenberry et al 9th ed.p. 864-868, 10th ed. ) • Protest-loud protest to departure of significant other, crying, trying to get to parent, rejects contact with strangers(eg.RN) • Despair-withdrawn from others, appears depressed, uncommunicative • Denial/Detachment- appears happy, interested in environment, forms superficial relationships (eg. RN). Usually seen after prolonged separation from parents.

20. Language Developement • Crying: 1st means of communication • Normal to cry 1-4 hr/day during first 6 wks of life; ↓s by 12 wks • Initially for physiologic need to discharge energy and d/t changes in CNS, later they cry for attention, fear or frustraton • Vocalization by 5-6 wks; 6mo imitate sounds • By age 1 can say 3-5 words and may understand as many as 100 words

21. Personal-Social • Show visual preference to human face as early as 1 wk • Social smile 6-8 wks • 3 mos: ↑ interest in environment • 4 mos: laugh aloud • 6 mos: personable; play peek a boo; extend arms to be picked up • 11 mos+: ↑independence; feed self, help dress, follow simple directions

22. Play • Narcissistic – revolves around own body • 3-6 mos: play alone w/rattle or soft toy or with someone else – begins to interact • 4 mos: show preference for toys & get excited if favorite food or object is given • 6 mos to 1 yr: peekaboo & pat-a-cake • Quality of personal interaction that occurs w/play is what is most imp • Play is referred to as solitary.

23. Temperament • Screening tools available: focus on sleep, feeding, play, diapering & dressing activities • Temperament influences the interaction between infant-parent & infant-others • The more dissonance bet. child & parent’s ability to accept and deal w/the behavior, the more risk for subsequent parent-child conflicts

24. Spoiled Child Syndrome • Excessive self-centered and immature behavior, resulting from failure to enforce consistent, age-appropriate limits • Demand to have own way, inconsiderate of others, intrusive, obstructive, manipulative behavior • It is NOT: crying in early infancy/colic, negativism, temper tantrums of toddlers, difficult temperaments or ADHD

25. Thumb Sucking/Pacifiers • Nonnutritive sucking of fingers in infancy & early childhood if OK unless it extends into late preschool yrs. • Malocclusion may occur if thumb sucking persists past 4-6 yrs or permanent teeth in • Pacifiers may ↑risk of malocclusion and influence social & speech development • Thumb sucking peaks at 18-20 mos • If persists in listless, apathetic child→ problem

26. Teething • First primary teeth: lower central incisors 6-10 mos • Upper central incisors 8-12 mos • Age of the child in mos – 6 = # of teeth for the 1st 2 yrs. • Encourage cold teething ring, oral Tylenol or ibuprofen, baby Orajel, etc. • Distinguish between teething (↓appetite, rubbing ear, mild temp) & illness (fever >102, n/v)

27. Shoes • Inflexible shoes w/hard soles can delay walking and impede foot development • Shoes provide protection only • Should be able to bend in half by squeezing the heel and toe w/your hand • Shoe size changes ~ every 3 mos bet 12-36 mos

28. Injury PreventionTable 12-6; pp 510-511 Hockenberry, 9th ed.Box 10-5, pp. 443-444, 10th ed. • Major cause of death, esp. 6-12 mos. • D/T increased locomotion & manipulative skills plus curiosity about the environment • Aspiration/Choking– common household items can be deadly to infants: coins, buttons, beads, broken toys, button batteries, bottle tops, safety tear down strips (plastic), baby powder, etc. • Food: nuts, hard candies, HOT DOGS (must be cut into small irreg. pieces), grapes, dried beans

29. Suffocation • 2nd only to homicide as leading cause of death in infants by injury • Latex balloons – leading cause – use mylar balloons; don’t inflate latex gloves • Bed/crib – blankets, pillows, wedging bet. Bed and wall, sharing bed w/adult, cords from drapes/blinds, mesh siding, crib slats • Plastic bags – occurs within minutes

30. Motor Vehicle Accidents--MVA • Leading cause of accidental death > 1 yr • Improper restraint or lap riding • Infants face rear til 20# and as close to 2 yr as possible • Middle of back seat is safest • Never place rear facing in front seat with air bag • Usually Public Health Dept or police station can inspect, give guidelines, & sometimes provide car seat • AAP Guidelines

31. Falls • Most common after 4 mos.- rolling over • Changing table, high chairs, walker, swings, infant seats • Heavy objects get pulled on and over as they try to stand up • May trip often when learning to walk – avoid slippery socks or shoes and watch clothing that could trip them up

32. Poisoning • Fairly safe until they become mobile • 2 yr olds highest, then 1 yr olds • Plants, batteries (esp. button), ingestion, inhalation (2nd hand smoke), purses, cigarettes, medicine, etc • Give parents poison control #, advice to keep meds and poisons locked and store high out of reach • Always store in original container

33. Burns • Smoke alarms near bedroom areas and on each level • Scald burns from tap water – lower hot water heater to 120 F – check bath water • Check food warmed in microwave – outside may be cool but inside hot • Turn handles toward back of stove, keep hot items far from edge of table or counter • Sunburn – no direct sun < 6 mos, then sunscreen and cover • Cover electric outlets and guard heat producing elements • NEVER leave child in car – esp. in hot weather

34. Drowning • Can occur in only inches of water • ALWAYS supervise in tub, baby pool, near toilet, or even buckets of water • Not recommended to take swim instruction if under 4 yrs. (AAP) – too young to understand risks • Increase risk of infection & convulsions from swallowing lg. amt. of water

35. Other Bodily Injury (Box 10-5 p.444 & Table 10-4 p. 445-6 10th ed.) • Sharp objects – toothpicks, knives, tools • Forks – wait til mastered spoon (18 mon) • Infant homicide – 6.4% • Excessive noise – hearing loss • Animal attacks – d/t jealousy • Nurses Role: anticipatory guidance; prepare parents for upcoming developmental changes and teach injury prevention; child proofing home; home safety checklist (p. 447 10th ed.)

36. Nutrition • 1st 6 mos – human milk best complete diet • 1st 4 mos only breast or formula • AAP recommends breast milk or formula for first year of life; then whole milk • No additional fluids; no water or juice in 1st 6mo. • Be aware of cultural beliefs: honey, water, sugared wine during early days of life • Honey → may predispose to botulism til 12 mos • Encourage breast fdg mom’s who return to work to pump q 3-4º and refrigerate milk

37. Expressed milk keeps for 5 days @ 39ºF • Can freeze for up to 12 mos in DEEP freezer • Maternal fatigue biggest threat to cont. • Never thaw or rewarm in microwave • Formula: do not use tap water unless sure of lead & fluoride content • Cow’s milk: unacceptable until 1 yr old; hi renal solute load & def. in Fe, Zn, vit.C

38. Solid Foods • Not before 4-6 mos because: • Not compatible w/digestion • Exposes to food antigens →↑ food allergy • Unable to push away or avoid fdg → overwt • Fe def. anemia • 2nd 6 mos: Fluoride begins if needed • Solid foods start: better head control, tooth eruption begins, GI tract matured, extrusion reflex gone, better eye-hand coordination, etc

39. Nutrition (cont) • Iron fortified cereal first: easily digested, low allergenic content • Add one new food @ a time, every 5-7 days • After 6 mo, can add juice w/cereal • Cont. cereal til 18 mo because need iron • Juice from a cup – not a bottle – no more than 5 oz/day; white grape juice best! Avoid apple, pear, prune, sweet cherry, peach & grape—high fructose & sorbitol abdominal pain. • Never warm juice in microwave—destroys Vit. C

40. Nutrition (cont) • Good reference on p. 492(9th ed.) p. 441 (10thed) for introducing solid foods in the first yr. • No set sequence for adding foods • Most important: only one solid introduced q 5-7 days → note if reaction occurs • By 1 yr. can eat well cooked table foods • Microwave not recommended – caution parents on dangers; see Homecare p.490 • Weaning: 2nd 6 months; introduce cup • Developmental milestones associated w/ fdg Box 12-4 p.491, 9th ed. Box 10-4 p. 440, 10th ed.