Infant and Toddler Growth and Development

1. Infant and Toddler Growth and Development Elisa A. Mancuso RNC, MS, FNS Professor of Nursing

2. Growth of Infant • Cephalocaudal (head → toe) • Proximodistal (trunk → periphery) • General → Specific (Large → fine muscles) • 1” a month during 1st 6 months • Average Ht 6 months 25 ½ inches 12 months 29 inches • Use recumbent length until 3 years • than standing (vertical height)

3. Weight • 5-7oz/wk until 5-6 months • Birth weight doubles at 6 month • Birth weight triples at one year • Always refer to kilograms 2.2 lbs = 1 kg • All medications based on weight in kg!

4. Head Circumference = HC Reflects brain growth • Posterior fontanele closes @ 2 mos. • Anterior fontanel closes @12-18 mos. • Measure (Forehead → Occiput) • For 1st3 years

5. Chest (CC) and Abdomen Chest = Head circumference @ 1 year • Measure @ nipple line. • Barrel chested as infant • Chest > Head after 3 years • After 1 year of age, • A/P transverse diameter = 1:2 Abdominal Girth • Measure above umbilicus • √ Abdominal distention • R/O liver or intestinal diseases

6. Growth Charts • Serial exams to assess growth progress • Plotted as percentiles: • 25th %, 50th %, 75th %, 95th %. • @ 95th % = Pt > 95% of kids. • Used to notice any ↓ or ↑in weight, height, or HC. • Specific charts for premature infants

7. Denver Developmental Screening Test (DDST) Denver II • Assesses from birth → 6 years • Age divided monthly → 24 months, • then q 3 mos. → 6 years • Not an intelligence test Four categories • Personal/Social • Fine motor/Adaptive • Language • Gross motor

8. Infant Reflexes • Moro - Startle • Loud sound = extension & abduction of extremities • Tonic neck – Fencing • Turn head to one side ® • arm & leg extend on ® side • Babinski • Dorsiflexion of big toe and toes fan out • All of above disappear in about 3-4 months

9. Developmental Skills Trust vs Mistrust (Birth to one year) • Social responsiveness to others • Trust develops with regular consistent, loving care • Self reliance and develops confidence Early infancy 0 - 3 months Smiles at significant other Holds head & chest up when prone Reaches for objects-grasp Laughs

10. Developmental Skills Early Infancy 4-6 months • Pulls self to sitting position • Sits with support • Rolls over = “Safety issue” • Tummy → back first at 2-3 months • Back → tummy by 6 months • stronger head and arm control • Transfers objects from hand to hand • Makes vowel sounds oh-oh

11. Developmental Skills Late Infancy 6-9 months • Hold own bottle • Develops preference for dominant hand • Probes with index finger • Feeds self finger foods • Pincer grasp @ 9 months • thumb and index finger used • Sits erect-unsupported • Crawls • Separation Anxiety ↑cries with strangers Object Permanance Searches for items outsidefield of vision

12. Developmental Skills 9-12 months • Triple birth weight and ↑ height by 50% • Releases objects • Pulls self to feet • Sits from standing position • Walks with help • independent walking can be as late as 18 months! • Responds to name • Recognizes no • Says 4 -5 words: mama, dada, no, bye • Teething (age – 6 = # of teeth) 12 mos – 6 = 6 teeth Cool cold items to chew on Tylenol 10-15 mg/kg q 4-6 hours

13. Developmental Tasks • Achieve physiological equilibrium • Rest, eat, play patterns • Develop basic social interaction • Desire for affection • Manage a changing body • ↑motor skills & eye-hand coordination • Learn to understand and control world • Develop a beginning symbol system • Communication

14. Immunizations • Regulated by CDC and American Academy of Pediatrics (AAP) www.cdc.gov/nip/vacsafe www.immunize.org • ↓ Infectious diseases = ↓morbidity & mortality • ↑ incidence of recent outbreaks: • immigration from poorly compliant countries • religious beliefs or cultural influences • ↓ trust of medical care or poor education • 2003 Nigeria stopped IPV • Rumors that IPV could transmit AIDS 2006 20% of kids<5 no IPV and ↑ polio outbreak • 2005 Amish Polio outbreak

15. 2009 Immunizations Hep B Hepatitis B Vaccine (IM) • Birth, one month and six months • Mom (+) HBsAg • give baby HBIG (0.5mL) & Hep B within 12H • @ 2 separate sites • 90% infected infants → chronic Hep B carriers • 25%-50% infected before age 5 RT HBV Carriers • ↑ Transmission risk in adolescents • All kids entering 7th grade must have Hep B 3 dose series

16. Immunizations IPV - Inactivated Polio Vaccine (SC) • 2, 4, (6-18) months and (4-6) years • Formerly used OPV –Virus shed • Contraindication; Allergy to neomycin HIB - Hemophilus Influenza Type B (IM) • 2, 4, 6 and (12-15) months • Not associated with Flu • Protects against many serious infections: • Epiglottitis and Bacterial Meningitis

17. Immunizations PCV7 - Polysaccaride Conjugate Vaccine- (Prevnar) (IM) • 2,4,6 and (12-15) months PPV – Pneumococcal Polysaccharide (IM) • One dose > 2 years Protects against Strep pneumonia • 6-12 months of age at high risk for S. pneumoniae ↑ Risk patients • Sickle cell disease, HIV/immune deficiency • chronic cardiac or pulmonary etc • Must receive PPV vaccine in addition to PCV

18. Immunizations DTaP - Diptheria, Tetanus and acellular Pertussis (IM) Diptheria • Rare throat infection • Gray/yellow film • difficult to remove • Air flow obstruction • Sepsis Tetanus • Clostridium produced in infected wounds • Severe muscle extension

19. Immunizations Pertussis • Gram negative bordetella pertussis • “whooping cough” • Post-tussive vomiting • Cyanosis • Subconjuctival hemorrhage Three stages: • catarrhal, paroxysmal (2 weeks) and decline • ↑ outbreaks in Adolescents and Adults RT ↓ titers www.pertussis.com

20. Immunizations DTaP Schedule • 2,4,6,15 months and 4-6 years for DTaP • √ Side Effect: Redness & swelling @ site • New booster recommendations 2005: • “Tdap” Adacel: one dose 11- 64 years or • Boostrix: single dose 10 -18 years of age • Adolescents 11-12 years of age should receive single dose of Tdap instead of Td (if up to date and have not yet received Td booster) • Need 5 year interval from Td to Tdap to ↓SE Contraindication: • Encephalopathy in 7 days of DTaP

21. Immunizations MMR - Measles, Mumps and Rubella (IM) Measles • Viral illness - macular/papular rash • Kopliks spots oral mucosa • Encephalitis/pneumonia Mumps • Inflammation salivary glands/parotid • Boys develop orichitis/sterility Rubella • Viral illness- rash (face → body → extremities) Pregnancy exposure: • Fetal deafness, cataracts, cardiac defects, encephalitis

22. Immunizations • MMR is live attenuated (weakened) vaccine • 12-15 months and 4 - 6years • Contraindication: Pregnancy Immunocompromised Allergy to neomycin

23. Immunizations Varicella (SC) • Varicella “chickenpox” • Live attenuated virus healthy children only • 12-18 months • 2nd dose @ 4-6 years • 2005 - All kids entering 6th grade • ↑Risk > 13 years • Give with MMR • MMRV new vaccine Contraindication • Pregnancy • Immunocompromised or • Allergy to neomycin

24. Immunizations MCV4 - Meningococcal Conjugate Vaccine 4 (IM) MPSV4 - Meningococcal Polysacharide (SC) • Protects against N.meningitids (not all strains!) • MCV4/ Menactra: • One dose 11-12 years or @ high school entry or college freshman in dormitories • (↑risk smoking and crowds) • MPSV4/Menomune: Children> 2- 10 years ↑risk factors Sickle cell disease.

25. Immunizations TIV -Trivalent Inactivated Vaccine – Influenza (IM) • Influenza virus → pneumonia and death • 2004 -152 pediatric deaths • ↑↑ # of cases in February • 6 mos - 5 years of age annually • > 5 years only high risk population. • 0.25ml<3 years or 0.5ml>3 years • Contraindication – Egg Allergy • √ Eat baked goods can have vaccine LAIV - Live Attentuated Influenza Vaccine > 5 years (2 doses 1st time)

26. New Vaccines Added Rotavirus vaccine Rototeq • Rotavirus is primary cause of acutegastroenteritis in US • Three oral doses given at 2, 4 and 6 months • Dosing must be complete by 8 months of age • No catch-up for older infants • Do not re-administer if infant spits up

27. New Vaccines Added Human Papillomavirus (HPV) • Non-enveloped dbl stranded DNA virus • >100 types with 15-20 oncogenic types • 75% of sexually experienced men and women age 15-49 years have had some type of HPV Quadrivalent HPV vaccine (Gardasil) • Protects against HPV 6,11, 16 & 18 • Type 16 and 18 account for approx 70% of cervical cancers • ACIP recommended 6/29/06 • Routine vaccination of girls 11-12 years but may begin @ 9 • Catch-up vaccination for adolescents and young women who have not been previously vaccinated • Not indicated in pregnancy or hypersensitivity to substances

28. New Vaccines Added HPV administration (3 separate doses 0.5ml IM ) • 1st dose on elective date • 2nd 2 months from first • 3rd 6 months after first dose SE: Very painful Syncope & tonic –clonic movements √ Pt remains seated or lies down x 15 minutes Compliancy Issues: • Moral issues can intervene • Study with boys shows = a good immune response • ↑ Vaccinate girls RT ↑↑ risk of Cervical CA

29. Only true contraindications to vaccine administration • Fever >102 • Immunocompromised: (No MMR & Varicella) • HIV, Leukemia, Lymphoma • Alkylating agents or Antimetabolites • Daily Corticosteroids Dose: > 2 mg/kg or 20 mg/day • Allergy to vaccine component • Vaccine Adverse Event Reporting System • (VAERS)

30. Congenital defects Cleft palate • 1/750 births cleft lip • 1/2500 births cleft palate • Incomplete closure of the roof of the mouth • 6th -10th week of gestation • Opening from uvula→ soft palate → hard palate → lip • Cleft palate 1st sign • Formula coming out of nose • Gloved finger to assess soft and hard palate in • newborn

31. Etiology Multifactorial • Genetic-familial tendency • ↑ in Asians and lowest in African Americans • ↑ Caffeine • ↑ ETOH • Dilantin or Valium • ↓Folic Acid ↓ Vit A Sequella • Feeding difficulties • Speech difficulties • High risk for Otitis Media Serous and Bacterial

32. Interventions • Review defect • Impact on infant • Before and after photos • Support Groups • 3P Feeding technique • Position - upright • Pore - soft, premie nipples • enlarged opening • Patience - burp frequently

33. Surgery • Lip repair usually 1-3 months • Protect incision line after operation • Palate repair @ 18 months • Supine with ↑ HOB • Elbow restraints • √ I & O

34. Tracheoesophageal (TEF) Fistula • Fistula • Opening between trachea and esophagus • Fluids enter lungs • ↑ Aspiration PN • Large amounts of air into stomach Esophageal Atresia EA • Esophagus ends in a blind pouch ↑ in Pre-term and/or Polyhydramnois • 30-50% multiple anomalies

35. TEF/ EA Clinical Signs • Increased salivation • Drooling • “3 C’s” • Choking • Coughing • Cyanotic episodes • Laryngospasms • Abdominal distension • Unable to pass NGT with atresia

36. Interventions • NPO • ↑ HOB>30º • Maintain patent airway • NGT to low intermittent suction • Prophylactic antibiotics • Aspiration PN • Surgery correction of fistula • ASAP

37. Safety in Infants Accidents leading cause of death btwn 6-12 mos Suffocation/Aspiration • # 1 cause of fatal injuries <1 year • √ toys, mobiles • No H2O mattress or pillows Falls • Walkers 45% Burns • H2O temp @ 160 scalds skin in 10 seconds • ↓ Temp to 120 Poisonings • Plants, Cleaners, Grandma’s purse √ meds Cars • Car seat < 1 year back seat, facing rear

38. Nutrition Vitamins for Infants • Fluoride • 0.25mg/day > 6 months - 3 years • Poly-vi-flor 1cc QD • >3 years ↑ 0.50mg/day • FeSO4 • 0.5mg/kg/day > 6 months • if BF mother not taking supplements • after 6 months fetal stores are depleted) Vit D 400 IU/day if BF mother not taking supplements

39. Breast Milk • Contains all nutrients and • A,B, E • Immunoglobulin IgA, T and B cells • Lacks Vit C, D and Fe • Twice sugar (lactose)= laxative effect • ↑ # of stools • ↑↑ lactalbumun more complete protein • ↓↓ caesin easier to digest

40. Formula • No more than 32 oz/day • No whole milk in infants! • No iron in milk • Infants unable to properly digest • ↑ ↑ irritation of intestinal mucosa, bleeding and anemia

41. Solids • Begin at 4-6 months • Too early introduction of solids • ↑ incidence of allergies and celiac disease. • No cereal in formula bottle! • Assess physiological readiness • ↓ Tongue extrusion reflex • ↑ Coordinated suck & swallow • Tooth eruption – ↑ biting & chewing • ↑ Pancreatic enzymes for complex nutrients • Introduce foods one at time • New food after 3 days: • Cereal → vegetables → fruits →meats → egg yolks Noegg whites <1 year No honey/corn syrup <2 years ↑ Risk of botulism No Nuts, Seeds or Popcorn

42. Kwashikor • Severe protein deficiency • Adequate caloric intake and ↑ ↑ carb diet • Mycotoxin mold found in intestines Signs and Symptoms • Scaly, dry skin and ↓ pigmentation • Hair thin/dry and coarse • Ascites • Edema RT ↓ protein • Muscle atrophy • Irritable, lethargic, withdrawn • Permanent Blindness Diarrhea→Infection →Death

43. Nursing Interventions • Assess degree of malnutrition • Neurological/muscular impairments • √ Developmental milestones • Hyperalimentation • ↑ Protein diet • Antibiotics • Skin Care • Collaborate with OT and PT

44. Skin Disorders Eczema (5-7% Infants) • RT allergies (egg, soy and cow’s milk) • ↑ Ig E levels RT ↑ Histamine, Prostaglandins, Cytokines • ↑ with stress • 90% develop asthma Signs and Symptoms • ↑ in winter • Skin Rash • Erythematous, edematous, • Pruritic, dry and cracked • ↑ Lesions in skin creases, Cheeks, forehead & scalp • ↑ Risk of secondary infections

45. Treatment • Hydrate • Brief bath with Dove soap • Lubricants –Eucerin cream • Topical steroids • Antibiotics if secondary infections • Elidel and Protopic 0.03% non-steroidal • Pimercrolimus and Tacrolimus • Only for children > 2 years • Black box warning • ?↑ risk of cancer

46. Impetigo • Toddlers and Preschoolers • ↑ incidence in Summer (hot/humid) • 1st Skin is broken via bug bite • infected - staph A or B strep • Very contagious • 1st Macular & Pruritic • 2nd Honey crusted, thick & bleed • Therapy • Wash lesion c warm soapy H2O • Soak and remove crusts • Bactraban BID 7 days PO Antibiotics PCN, EES, Lorabid, Zithromax

47. Sebborrheic Dermatitis Cradle Cap • Chronic inflammatory condition • Dysfunction of sebaceous glands • Infants produce a lot of sebum • Yellow scales from eyelids → Scalp • Therapy • Apply lotion, massage scalp Fine comb remove scales

48. Toddler 12-36 months • Growth slows – Physiological anorexia • Average weight gain 4-6 lbs/year • BW quadrupled by 2 ½ years • Height 3 inches/year • HC growth slows • A/P diameter 1:2 • Visual acuity 20/40 • Eyes can accommodate objects @ distance ↑ Neuromuscular control Manipulates objects & people

49. Psychosocial Development Autonomy vs. Shame and Doubt • “Me do” stage • Intense exploration of environment • Fighting for autonomy • Negativism “No” • Ritualistic behavior to control their environment • Body Image develops

50. Psychosocial • 2nd Separation Anxiety • Cling and cry when left by parent • Be honest regarding separation do not disappear!! • Body image develops • knows certain body parts: eye, “pee pee” • Begins to acquire socially accepted behaviors