Growth & Development 0-1 Year and Implications in the Hospitalized Child

1. Growth & Development 0-1 Year and Implications in the Hospitalized Child By Prof. Unn Hidle Updated 2010

2. Recommended for Pediatric Growth & Development (Videos): * The Infant – strongly recommended* Pediatric assessment - strongly recommended* Promoting growth of The hospitalized child* (Toddler / pre-school / school age)

3. Biological development • During infancy, physical changes and developmental achievements are tremendous • Acquisition of fine and gross motor skills occurs in an orderly head-to-toe and center-to-periphery sequence (cephalocaudal-proximodistal) • Increases in length occur in sudden spurts (growth spurts) rather than a slow, gradual pattern. • Proportional changes: • by 6 months, the birth weight has at least doubled • by 1 year of age, the birth weight has tripled. • By 1 year of age, the birth length has increased by almost 50%.

4. Head growth is also rapid and an important determinant of brain growth. • By the age of 1 year, the head size has increased by almost 33%. • Closure of the cranial sutures: • posterior fontanel fusing by 6-8 weeks • anterior fontanel closes by 12-18 months • The infant growth is strongly influenced by genetic, metabolic, environmental, and nutritional factors

5. Growth charts are extremely important • By the end of the first year: • Brain has increased in weight approx. 2 ½ times • The primitive reflexes are replaced by voluntary, purposeful movements, and new reflexes that influence motor development appear.

6. 3 month old infant

7. 8 month old infants

8. Sensory Changes • Visual acuity gradually improves with binocular fixation: • Binocularity= fixation of two ocular images into one cerebral picture (fusion) begins to develop by 6 weeks of age and should be well established by age 4 months. Lack of this results in strabismus and must be detected early to prevent permanent blindness • Depth perception (stereopsis) begins to develop by age 7-9 months but may exist earlier as an innate safety mechanism. • Visual preference for looking at the human face

9. Fine Motor Development • Use of the hands and fingers in the prehension (grasp) of an object. • Grasping occurs during the first 2-3 months as a reflex and gradually becomes voluntary • The palmar grasp, using the whole hand, is replaced with a pincer grasp in which the infant uses the thumb and index finger • 8-9 months: crude pincer grasp (use parts of the hand) • 10-11 months: neat pincer grasp (i.e. raisin)

10. 1 year old infant

11. Gross Motor Development • Includes posture, head balance, sitting, creeping, standing, and walking. • Primitive reflexes role in development of gross motor skills. • Righting reflexes (new reflexes that influence motor development) elicit certain postural responses, particular of flexion and extension • rolling over • crawl position • maintaining normal head-trunk-limb alignment during all activities

12. Head control: • Full-term newborn: Momentarily hold the head in midline when prone. • By 3 months of age, infants can hold their head well beyond the plane of the body. • By 4-6 months head control is well established

13. Rolling over: • From the abdomen to the back: 5 months • From the back to the abdomen occurs at 6 months • The parachute reflex • Protective response to falling: 7 months • Sitting: • Follows progressive head control and straightening of the back. As the spinal column straightens, the infant can be propped in a sitting position. • 7 months: sit alone, leaning forward on their hands for support. • 8 months: sit unsupported. • 10 months: maneuver from a prone to a sitting position.

14. Crawling • 9 months: propelling forward with belly on the floor, progresses to creepingon hands and knees (with belly off the floor) • “Cruising” • ~11 months: walk while holding onto furniture • Infant who does not pull to a standing position by 11-12 months of age should be further evaluated for possible developmental dysplasia of the hip.

15. Cognitive Development • Piaget’s Theory: • Theory most commonly used to explain cognition or the ability to know • Sensorimotor Phase: From birth to 24 months. It is composed of 6 phases. • Importance of phases include: • Reflex behavior becoming simple repetitive acts • Separationfrom object or environment • Object permanence • Symbols or Mental representation • Infant think of an object/situation without experiencing it

17. Psychosocial Development • Erikson: • Developing a Sense of Trust (trust vs mistrust) • Phase I (birth – 1 year) acquiring a sense of trust while overcoming a sense of mistrust. • The trust that develops is a trust of self, of others, and the world (i.e. trust that they will be fed, comforted, stimulated etc.) • The crucial element for the achievement of this task is the quality of both the parent/caregiver • When this synchrony fails to develop, mistrust is the eventual outcome

19. ATTACHMENT

20. Attachment • The importance of human physical contact cannot be overemphasized • Attachment may not have a biological significance since caretakers other than the biological parents can develop a stronger attachment to that child (i.e. adoption) • If no attachment: ADHD, RAD (reactive attachment disorder, i.e. institutionalized) • Feral Children: http://www.feralchildren.com/en/index.php

21. Separation Anxiety • Begins between the age of 4-8 months • Infant begins to have some awareness of self and mother as separate beings • Object permanence is developing • Separation anxiety develops and is manifested through a sequence of behaviors, beginning with protest

22. Separation Anxiety • Separation anxiety is a major stressor from middle infancy (6 months) throughout the preschool years, which is also called anaclitic depression • Preschoolers: Refusing to eat, difficulty in sleeping, crying quietly for their parents or withdraw from others • School-age children: Better able to cope with separation in general, but the stress of hospitalization may regress them to an earlier stage where separation is more difficult.

23. Separation anxiety

24. Strategies to Make Separation Easier • Primary nursing goal is to prevent separation, especially in children < 5 years • Family-centered care: Collaboration between the health care provider, the child and the family. I.e., parent sleeping at the bedside, “parent tray”, parent’s active participation in the child’s care • ROUTINE and NORMALIZE child’s day!

25. Stranger fear • Sex, age, and size of the stranger – female, younger age, and smaller size (including kneeling or sitting rather than standing) being less stressful • Approach – loud, sudden, intrusive approach causing more distress • Child’s proximity to parent – closer to parent (on parent’s lap rather than in infant seat) being less stressful

26. LANGUAGE DEVELOPMENT

27. Language Development • Sequence: • Crying: Distinguishing different • Vocalization: 5-6 weeks - small throaty sounds. Then vowel sounds are added followed by consonants. • “Baby Language” based on crying sounds: Christine Dunstan: http://www.dunstanbaby.com/cms/index.php?page=us-home • “NO!” - The meaning is comprehended by 9-10 months • By age 1 year, they can say 3-5 words with meaning and may understand as many as 100 words

28. A parent’s favorite…

29. PLAY • Infancy • Activities are primarily narcissistic and revolves around their own body. • Body parts are primarily objects of play and pleasure (think of Freud). • 6 months to 1 year • Play involves sensorimotor skills. • Actual games such as peekaboo and pat-a-cake • Play is much more selective, not only in terms of specific toys but also in terms of “playmates.”

30. Stimulation is as important for psychosocial growth as food is for physical growth • It isNOTsufficient to place a mobile over a crib and toys in a playpen for a child’s optimum social, emotional, and intellectual development

31. Solitary Play

33. Parallel Play

36. Appropriate Developmental Toys See Hand-Out!

37. TOYS • The types of toys given to the child is much less important than the quality of personal interaction that occurs (i.e box). • Always remember growth and development in terms of SAFETY!

38. Developmental Assessment Denver II

39. Denver II

40. Importance of distinguishing between DEVELOPMENTAL SCREENING (i.e. Denver II), and • IQ test (Stanford-Binet)

41. Screening Procedures • Designed to identify quickly and reliably those children whose developmental level is below normal for their age and who therefore may require further investigation • Since the passage of P.L. 99-457, the Education of the Handicapped Act Amendment of 1986, much greater emphasis has been placed on developmental assessment of children with disabilities • Nurses play a vital role in providing this service

42. Denver II • Denver Developmental Screening Test (DDST) and its revision, the DDST-R have been revised, re standardized, and renamed the Denver II • Before administering the Denver II, the examiner should be trained by and receive a certificate from a master instructor who has been trained by the Denver faculty

43. Each item was evaluated to determine if significant differences exist on the basis of sex, ethnic group, maternal education, and place of residence • When evaluating children who are delayed on one of these items, the examiner can look up norms for the subpopulations to consider if the delay may be caused by socio cultural or environmental differences • Soap box: “Would we question the test?”

44. Testing • Adjusted age: • Prior to the test, prematurely born children should be identified. • Up to 24 months of age, allowances are made for prematurely born children by subtracting the number of weeks of missed gestation from their present age and testing them at adjusted age.

45. Emphasize that the child is not expected to perform each item on the test • It is the nurse’s responsibility to properly inform parents about any testing or screening procedure before its administration so that they are fully aware of its purpose and intent • Prepare toddlers and preschoolers for the procedure by presenting it as a game

46. Categories tested • Personal-Social: getting along with people and caring for personal needs • Fine Motor-Adaptive: eye-hand coordination, manipulation of small objects and problem-solving • Language: hearing, understanding and using language • Gross Motor: sitting, walking, jumping, and overall large muscle movement

47. Perform each item quickly and present only one toy from the kit at a time since children are easily distracted • Temporary factors that may interfere with the child’s performance include: • Fatigue • Illness • Fear • Hospitalization • separation from the parent • general unwillingness to perform the activity

48. In each sector, administer • 3 items nearest to and LEFT of the age line • All items on (intersecting) the age line • Continue until 3 “fails” occur (of items)

49. Following completion of the Denver II: • Ask the parent if the child’s performance was typical of behavior at other times. • If it was not typical of usual behavior, it is best to defer any scoring or discussion of results. • The test should be rescheduled for a time when the child is more likely to cooperate

50. Denver II Scoring • Interpretation of Denver II scoring: (See Denver II test booklet) 1) Advanced: Passed an item completely to the right of the age line (passed by fewer than 25% of children at an older than the child) 2) OK: Passed, failed, or refused an item intersected by the age line between the 25th and 75th percentiles 3) Caution: Failed or refused items intersected by the age line on or between the 75th and 90th percentiles 4) Delay: Failed an item completely to the left of the age line; refusals to the left of the age line may also be considered delays, because the reason for the refusal may be inability to perform the task