CHAPTER I

Introduction

Growth is the progressive increase in the size of a child or parts of a child.

Development is progressive acquisition of various skills (abilities) such as head support,
speaking, learning, expressing the feelings and relating with other people. Growth and
development go together but at different rates.

Your new born will grow and change more in the first year of life than during any
time, making it an exciting and sometimes nerve-wracking age for parents. Every baby
is different and will grow at his or her own pace, during the first year the baby will
change dramatically in five areas of development: physical, cognitive, emotional and
social, language, and sensory and motor skills.

Growth and Development

For the first several months, new born will only need breast milk or formula for
proper nutrition. When the baby is able to sit upright in a highchair and begins showing
interest in food, that’s the time to start transitioning the baby to solid foods with pureed
foods and cereals (iron-fortified).

Physical Development

By four months babies grow about 3 inches and gain an average of 4.5 pounds
from their birth length and weight. Their head circumference also grows between .25
and .5 inches a month during the first year of life. By six months, their weight has
usually doubled from birth, averaging a gain of .5 oz to 1 oz. a day. Growth may begin
to slow around this time for infants and become more gradual. By their first birthday,
babies have grown about 10 in. in length and their weight has tripled. Some babies may
begin teething at this age, with the first tooth coming in between four to 18 months.

Cognitive Development

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 While a baby’s cognitive ability and senses develop, his or her ability to interact
with the people and environment around him or her increases. Beginning around one to
two months of age, babies will turn their head towards and take an interest in objects
and people. By three months, this interest evolves into an ability to anticipate familiar
things and to react to them.

During the fourth month of life, your baby's vision will improve, and most are able
to link the senses of sight, taste, hearing and touch together to form an identity of one
object or person, called sensory integration. Between six and nine months of age,
babies begin to recognize those familiar sights, sounds and touches. They are also able
to better understand absence and create memories, a skill called object permanence.
After gaining a better understanding of what is familiar, babies around nine to twelve
months of age become more prone to watching others and exploring objects and
environments. Personality, curiosity and emotion become more apparent during this
age.

Emotional and Social Development

As infants at one month begin to better express their feelings (often with alert,
widened eyes and a rounded mouth) the bond between parents and baby strengthens.
By two months, your baby may begin to interact with you by smiling, called the “social
smile,” along with making eye contact and moving arms. As early as two to four months,
babies will grow attached to familiar caregivers. At four to six months of age, babies
become more social, and their facial expressions can now readily express emotion,
such as anger and happiness. Between six to nine months, they will use those
expressions to communicate both preference for caregivers and anxiety at their
absence. They may cry, turn away or become upset when separated from caregivers,
called separation anxiety, or act uneasy around strangers, called stranger anxiety.

Towards their first birthday, around nine to twelve months, separation anxiety
and stranger anxiety may decrease, while babies increasingly demonstrate preference
and affection for caregivers. Independence also increases as your baby may begin to
explore more by crawling or even walking.

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Language Development

While infants do not usually begin to speak in the first year of life, development of
language skills does allow them to understand and to communicate with others.
Although not yet understanding what's being said, around one month, infants will turn to
a soft voice, especially that of a parent’s. By three to six weeks, they begin to use
certain cries to express different needs, such as hungry or sleepiness.

What we refer to as "baby talk” begins at two months with cooing, or “ih” and “uh”
sounds. Babies may also watch speaking mouths and respond. Around five months,
babies progress to babbling, or repeating sounds for attention and expression. They
may even begin to recognize their name.

By six to nine months, infants will begin to imitate sounds and rhythms of speech.
They may still babble to communicate but can also recognize the word “no,” respond
when told to “wave bye-bye” and begin to understand simple commands. By their first
birthday, the words “mama” and “dada” can be tied to parents by infants and even used.
The names of other family members or pets may also be understood when they hear
them.

Comprehending more words by this age, babies will tend to jabber with tone and
inflection that mimics conversation.

Sensory and Motor Development

As muscles begin to strengthen during the first month, most babies are able to lift
their head for a short time while lying on their stomach. Other limb movements at this
time may be due to newborn reflexes, such as the startle reflex, where a baby throws
out his or her arms and spreads fingers when confronted by a loud noise or surprise.
These reflexes begin to fade away by six weeks. At three months, infants now have
better control of their head and begin to appear fascinated with their hands. They will
also now knowingly hold onto the fingers of others as a way to gain attention. Around
four months, control and balance of their head, neck and trunk will allow them to begin
to roll over.

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Still unsteady at four months, babies might sit with their hands out front to balance them
in a tripod position. However, by six to nine months, leg and trunk coordination have
improved, allowing babies to sit, crawl and sometimes even pull themselves up to stand.
At seven months, your baby's eyes have developed almost to the same extent as your
own. In the few months before their first birthday, more control over their hands and
fingers let baby’s better grab small objects with their thumbs and index fingers, rather
than their palms. As they start to learn and interact with all their senses, babies have a
tendency to put objects in their mouth, making baby-proofing your home extremely
important, until they are able to walk independently.

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 A. BACKGROUND OF THE STUDY

INTERNATIONAL

Growth and Developmental milestones serve as the basis of most standardized

assessment and screening tools. Although these screening tools provide the clinician
with a structured method of observing the infant’s progress and help define a
developmental delay, many lack sensitivity. Parental concern in the face of normal
results in developmental screening should not be disregarded. Focusing narrowly on
discrete milestones may fail to reveal atypical organizational processes that are
involved in the child’s developmental progress. Thus, it is important to analyze all
milestones within the context of the child’s history, growth, and physical examination as
part of an on-going surveillance program. Only then is it possible to formulate an overall
impression of the child’s true developmental status and the need for intervention.

Although milestones form the foundation of the discussion, the primary intent of
this article is to provide broader insights into infant developmental processes and to
help the clinician recognize warning behaviours (“red flags”) indicative of developmental
deficits. The milestone ages are not repeated in the text to allow a more fluid discussion
of developmental themes within each domain. Milestones have been organized into
domains to assist the clinician in recognizing their independence as well as their
interrelationships. Tables illustrating all domains at each age can be found in Vaughan
(see Suggested Reading). Problem-solving and language milestones facilitate early
identification of cognitive deficits. Adaptive skills (i.e., skills related to independence in
feeding, dressing, toileting) traditionally have been included within the fine motor
domain. However, because these milestones are influenced by the social environment,
we have included them in a “psycho-social domain.” Lists for emotional and
socialization milestones also are included in this domain. In contrast to motor and
cognitive milestones, psychosocial behaviours are influenced more by extrinsic factors,
making them less well-defined.

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EVOLUTION OF DEVELOPMENTAL THEORY

Developmental theory has been shaped by the persistent debate of whether

nature (intrinsic forces) or nurture (extrinsic forces) is the predominant influence. At the
turn of the century, developmental theories promoted nature as the major influence.
Gesell (early 1900s) was one of the first to study infant development systematically and
establish developmental norms. Development was seen as a function of neurologic
maturation and growth. Because advancing age and genetic endowment were the chief
mechanisms for change, babies were believed to develop at a predetermined biological
pace, with parents needing to do little more than provide a good nurturing environment.

By mid-century, theories that stressed the importance of nurture began to prevail.

Pavlov (1930s), Watson (1950s), and Skinner (1960s) promoted the opposing view that
development was a function of learning. Operant conditioning (positive and negative
reinforcements through social interactions or environmental changes) promoted learning
and shaped the child’s development. This line of thinking formed the philosophical basis
for the Head Start program of the 1960s. Freud (1920s) and Erikson (1950s) promoted
developmental progress as a function of the resolution of conflict. The quality of the
infant’s relationships with key individuals was considered central to future development.

During the second half of the century, the name of Piaget became almost
synonymous with child development. Piaget was the first to describe the infant as
having intelligence. For centuries, it had been assumed that the infant’s mind was a
“blank tablet waiting to be written on.” Because infants could not tell us what they were
experiencing, it was believed that they saw and heard little and thought even less, with
consciousness as adults knew it not existing. Piaget revealed that infants were, indeed,
capable of thinking, analysing, and assimilating. He viewed development as stage-like
cognitive changes. The child actively explores objects in an effort to understand his or
her environment. Depending on the developmental stage, a child organizes this
information to form new theories about the way the world works.

It was not until the last part of this century that emotional and social development
began to receive the same degree of attention as that given to the motor and cognitive
domains. Research has revolved around theories regarding infant expression of

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emotion (Mandler, 1970s), attachment (Bowlby, 1960s; Mahler, 1970s; and Ainsworth,
1980s), and temperament (Thomas and Chess, 1970s). Once it was recognized that
new born could demonstrate distress (pain and hunger), interest, and disgust, these
facial expressions have been used to study information processing in infancy prior to
the age when thoughts can be verbalized. As the 20th century comes to a close,
remarkable advances in behavioral genetics, together with recent discoveries regarding
innate infant abilities, have swung the pendulum back in favor of nature as the primary
influence on the developmental process.

DEVELOPMENTAL SNAPSHOTS: THE FIRST TWO YEARS OF LIFE

Before dissecting infant development into discrete steps within each

developmental domain, it is valuable to view the infant at discrete intervals. These 6-
month “snapshots“ are displayed graphically. This gestalt approach may help the
clinician make sense of the interrelatedness of the precise changes within each
developmental domain. These four snapshots illustrate several generalizations about
neuro-developmental maturation over time: Responses to stimuli proceed from
generalized reflexes involving the entire body, as seen in the newborn (and fetus), to
discrete voluntary actions that are under cortical direction. This specialization allows the
child to move from obligatory symmetric reactions when attending to a stimulus (ie,
vocalizations, arm waving, and kicking) to voluntary, asymmetric, and precise
movements toward a stimulus (ie, grasping with one hand and inspecting with the
other).

Growth milestones are the most predicable, although they must be viewed within
the context of each child’s specific genetic and ethnic influences. It is essential to plot
the child’s growth on gender- and age-appropriate charts. Charts now are available for
some ethnic groups as well as for a few genetic syndromes (eg, Down and Turner
syndromes). Fetal weight gain is greatest during the third trimester. During the first few
months of life, this rapid growth continues, after which the growth rate decelerates. Birth
weight is regained by 2 weeks of age and doubles by 5 months. Height does not double
until between 3 and 4 years of age. Head growth during the first 5 or 6 months is due to

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continued neuronal cell division. Later, increasing head size is due to neuronal cell
growth and supporting tissue proliferation.

RED FLAGS IN PHYSICAL GROWTH

Occipitofrontal Circumference

Large and small head size both are relative red flags for developmental
problems. Microcephaly is associated with an increased incidence of mental retardation,
but there is no straightforward relationship between small head size and depressed
intelligence. As a reflection of normal variation, microcephaly is not associated with
structural pathology of the nervous system or with low intelligence. Furthermore,
microcephaly can be seen with above-average cognitive capability. Micro-cephaly
associated with genetic or acquired disorders reflects cerebral pathology and almost
always has cognitive implications.

Macrocephaly may be due to hydrocephalus, which is associated with an

increased incidence of cognitive deficits, especially learning disabilities. Macrocephaly
without hydrocephalus, far from being a predictor of advanced intelligence, also is
associated with a higher prevalence of cognitive deficits. It may be due to metabolic or
anatomic abnormalities. In about 50% of cases, macrocephaly is familial, and the
implications are benign in terms of intellect. When evaluating infants whose
macrocephaly is isolated, the finding of a large head size in one or both parents can be
reassuring.

Height and Weight

Although the majority of individuals who are of below- or above-average size are
otherwise normal, there is an increased prevalence of developmental disabilities in
these two subpopulations. Many genetic syndromes are associated with short stature;
large stature syndromes are less common. Again, when considering deviation from the
norm in the specific child, family characteristics must be reviewed. The concept of mid-
parental height is useful in determining whether a given child’s size is appropriate for his
or her familial growth pattern.

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Dysmorphism

Although most isolated minor dysmorphic features are inconsequential, the

presence of three or more may indicate the presence of developmental dysfunction.
Almost 75% of these minor superficial dysmorphisms can be found by examining the
face, skin, and hands. The presence of both minor and major abnormalities may
indicate a more serious genetic syndrome. In many instances, dysmorphic features will
lead to the diagnosis of a clinical syndrome during the neonatal period and predate the
recognition of any neurodevelopmental deficits.

Motor Development

To make a meaningful statement about an infant’s motor competence, the

pediatrician should organize data gathered from the history, physical examination, and
neuro-developmental examination according to the following schema: 1) motor
developmental milestones, 2) the classic neurologic examination, and 3) cerebral
neuromotor maturational markers (primitive reflexes and postural reactions). Motor
milestones are extracted from the developmental history as well as from observations
during the neurodevelopmental examination. Reference tables of sequential gross and
fine motor milestones are necessary

Results of assessment in any domain is summarized best as indicating a

developmental age for the child. This approach makes it possible to consider the child in
terms of his or her level of functioning compared against chronologic age. For example,
the developmental quotient (DQ) is the developmental age divided by chronologic age
times 100 (see Example below). This provides a simple expression of deviation from the
norm. A quotient above 85 in any domain is considered within normal limits; a quotient
below 70 is considered abnormal. A quotient between 70 and 85 represents a gray area
that warrants close follow-up. Values in the upper limit of normal do not particularly
indicate supernormal abilities. Whether truly gifted athletes can be recognized early by
use of this method is thought-provoking but speculative.

GROSS MOTOR DEVELOPMENT

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 Gross motor development proceeds from a sequence of prone milestones
(beginning with head up and ending with rolling), to sitting, and then through a
standing/ambulating sequence. Motor milestones do not take into account the quality of
a child’s movement. These sequences must be considered in the context of the motor
portion of the neurologic examination, including observations of station and gait, where
qualitative features can be assessed. However, the neurologic evaluation of tone,
strength, deep tendon reflexes, and coordination is difficult in very young infants
because of the subjective nature of the assessments and the infant’s limited ability to
cooperate. Clinical experience is essential for obtaining accurate and useful information.

Eliciting reflexes requires patience and repeated, yet gentle, trial and error.
Muscle tone (passive resistance) and strength (active resistance) are a challenge to
distinguish in the contrary infant. The best clues can be obtained from observation, not
handling. Spontaneous or prompted motor activities (eg, weight-bearing in sitting or
standing) require adequate strength. Thus, weakness may be appreciated best from
observing the quality of stationary posture and transition movements. The Gower sign
(arising from sitting on the floor to standing, using the hands to “walk up“ one’s legs) is a
classic example and indicative of pelvic girdle and quadriceps muscular weakness. Not
until 2 to 3 years of age does the neurologic examination become easier and more
meaningful as cooperation improves.

Station refers to the posture assumed in sitting or standing and should be viewed
from anterior, lateral, and posterior perspectives, looking for body alignment. Gait refers
to walking and is examined in progress. Initially, the toddler walks on a wide base,
slightly crouched, with the arms abducted and slightly elevated. Forward progression is
more staccato than smooth. Movements gradually become more fluid, the base
narrows, and arm swing evolves, leading to an adult pattern of walking by 3 years of
age.

The motor neuromaturational markers are the primitive reflexes, which develop
during gestation and generally disappear between the third and sixth month after birth,
and the postural reactions, which are not present at birth but develop sequentially

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between 3 and 10 months of age. The Moro, tonic labyrinthine, asymmetric tonic neck,
and positive support reflexes are the most useful clinically. As with all true reflexes,
each requires a specific sensory stimulus to generate the stereotyped motor response.
Normal infants demonstrate these postures inconsistently and transiently; those who
have central neurologic (ie, cerebral) injuries show stronger and more sustained
primitive reflex posturing. Primitive reflexes are somewhat difficult to gauge, even in
expert hands. The appearance of postural reactions in sequence beginning after 2 or 3
months of age is easier to elicit clinically and can provide great insight into the
neuromotor integrity of young infants. Postural reactions are sought in each of the three
major categories: righting, protection, and equilibrium. These movements are much less
stereotyped than the primitive reflexes, and they require a complex interplay of cerebral
and cerebellar cortical adjustments to a barrage of sensory inputs (proprioceptive,
visual, vestibular). They are easy to elicit in the normal infant but are markedly slow in
appearance in the infant who has central nervous system damage

FINE MOTOR DEVELOPMENT

In the first year of life, fine motor development is highlighted by the evolution of a
pincer grasp. During the second year of life, the infant learns to use objects as tools
during functional play. In the early months, the upper extremities assist with balance
and mobility. As balance in the sitting position improves and the infant assumes biped
mobility, the hands become more available for manipulation of objects—their ultimate
function. Primitive reflexes are integrated, and the upper extremities come under cortical
control. Reaching becomes more accurate, and objects are brought to the mouth for
oral exploration. As development progresses from proximal to distal, reaching and
manipulative skills are enhanced further, and precise manual exploration replaces oral
exploration. During the second year, fine motor skills are assessed by observing the
manner in which the hands use objects as tools (eg, blocks to build and crayons to
draw). The close association between gross and fine motor skills in the first year of life
evolves into a similar relationship between problem-solving and fine motor skills during
the second year. One skill enables or promotes the development of the other. If

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progress in manual dexterity is slow, this may impede cognitive development via
manipulation of objects.

RED FLAGS IN MOTOR DEVELOPMENT

It is important to begin the motor evaluation by observing the infant. Pay

particular attention to the hands; persistent fisting at 3 months of age often is the
earliest indication of neuromotor dysfunction. Spontaneous postures (eg, froglegs and
scissoring) provide visual clues to hypotonia/weakness and spastic hypertonus,
respectively. Delays in thea ppearance of postural reactions herald future delays in
voluntary motor development. An infant will be unable to sit or walk independently
without intact protective and equilibrium mechanisms. Abnormal movement patterns
may indicate pathology. For example, early rolling (1 to 2 months), pulling directly to a
stand at 4 months (instead of to a sit), W-sitting, bunny hopping, and persistent toe
walking may indicate spasticity. Hand dominance prior to 18 months of age should
prompt the clinician to examine the contralateral upper extremity for weakness
associated with a hemiparesis.

Analysis of the information gathered in these areas makes it relatively easy for
the practitioner to reassure him- or herself (and the parents) about a child’s motor
competence or to identify motor impairment at an early age. Once a motor abnormality
has been identified, further assessment of its exact nature and etiology is essential. This
almost always warrants referral to an appropriate subspecialist or subspecialty team.
Based on clinical examination and history, the astute clinician usually can decide into
which category the motor disorder falls: 1) static central nervous system disorders, 2)
progressive diseases, 3) spinal cord and peripheral nerve injuries, or 4) structural
defects.

Cognitive Development

Cognitive processing skills are the substrate for intelligence and include a wide
range of abilities.

Intellectual development depends on learning that contains three components:

attention, information processing, and memory (which includes both encoding and

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retrieval of information). Intellectual development is reflected in advancing abilities to
comprehend, reason, and make judgments. Standardized intelligence tests generally
measure two forms of intelligence in the school-age child: verbal and performance (or
nonverbal). Such standardized tests are not available to measure infant intelligence.
How then, does one recognize the attributes of verbal and nonverbal intelligence in
infants? In the past two decades, the discovery of visual habituation techniques to
assess infants’ attention was considered a breakthrough in the study of infant cognition.
It is exemplified by one study that describes 4-day-old infants listening to a long series
of “ bee-see-lee” sounds. When a novel “da” sound was heard, the infants responded
with a change in heart rate and faster, stronger sucking on a pacifier, thereby indicating
that very young infants can perceive differences in vowel sounds.

More complex studies using simultaneous auditory and visual stimuli indicate that
infants also are capable of organizing perceptions across sensory modalities (cross-
modal matching) without the language skills to describe them. For example, 11-month-
old infants were presented a sequence of continuous and interrupted pure tones. Two
pictures were in the infants’ view throughout the experiment: one contained a
continuous line, the other a dashed line. The infants consistently matched the correct
visual stimulus to the auditory one, inferring cross-modal matching and some
rudimentary understanding of the concept of interruptedness. Using these techniques, it
has been demonstrated that infants younger than 1 year old can form a wide range of
fairly complex categorical representations, including those for faces, color, geometric
shapes, and orientation of lines.

The attempts to measure infant responses precisely, such as those described

previously, depend on sophisticated technology, including infrared photography for
tracking infant eye gaze and pupillary dilatation, videotaping of facial reactions, and
electrophysiologic monitoring of heart rate and evoked potentials. The primary
pediatrician can best estimate infant intelligence by evaluating problem-solving and
language milestones. Language is the single best indicator of intellectual potential;
problem-solving skills are the next best measure. Gross motor skills correlate least with

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cognitive potential; most infants who are diagnosed later with mental retardation walk on
time.

PROBLEM-SOLVING

Problem-solving skills consist of manipulating objects to solve a problem (eg,

choosing the correct opening for a circular shape in a three-piece form board). The
infant’s ability to solve a problem depends on intact vision, fine motor coordination, and
cognitive processing. During the early weeks of life, the infant explores the environment
visually. Later, these visual experiences reinforce movement. As the upper extremities
come under visual guidance, reaching and grasping are enhanced. At first, the infant
brings objects to the mouth for oral exploration. Later, the infant visually examines an
object held in one hand while manipulating it with the other. Isolation of the index finger
promotes more refined manipulation of the various parts of objects, and the infant
becomes successful in discovering how they work (eg, fingering the clapper of the bell).
Mouthing of objects becomes less appealing. This precise manual-visual manipulation,
triggered by a heightened curiosity and facilitated by a longer attention span, heralds
true “inspection” of objects. The infant is progressing from “learning to manipulate” to“
manipulating to learn.” Improved macular vision (via myelination of the fovea) and
refinement of the pincer grasp promote inspection of progressively smaller objects. As
cognitive abilities continue to advance, the infant learns to shift attention between two
objects (one in each hand), compare, make choices, and discard or combine objects.
This sensory-motor phase of learning is the foundation for ongoing nonverbal
intellectual development.

The 1-year-old child recognizes objects and associates them with their functions.
Thus, he or she begins to use them functionally as“ tools ” instead of mouthing,
banging, and throwing them. This child has left the period of sensory-motor play and
entered the stage of functional play. Play serves as a window into the infant’s thoughts
and becomes particularly important during the next stage of symbolic play. At this point,
the infant uses toys that represent real objects in actions toward him- or herself (putting
a toy telephone to the ear and vocalizing) and later in actions toward dolls or teddy
bears (putting a toy tea cup to the doll’s mouth). The use of symbols lays the foundation

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for imaginary play. This next stage of play usually does not appear until 24 to 30 months
of age.

The interdependence of language and problem-solving development becomes

stronger as the child begins to label objects and actions. Midway through the second
year, this ability to label and categorize allows the child to match objects that are the
same (car to a car and spoon to a spoon) and later to match an object to its picture.
Nonverbal intelligence is assessed by observing the infant interact with test objects. In
the older child, it is assessed through standardized pencil and paper tasks or
computerized tests.

One aspect of nonverbal cognitive development deserves extra attention: object

permanence, a concept studied extensively by Piaget. Prior to the infant’s mastery of
object permanence, a person or object that moves “out of sight“ is“ out of mind”; its
disappearance does not evoke a reaction. The ability to maintain an image of a person
develops before that of an object. The child will show interest in peek-a-boo play, and
separation anxiety will occur when a loved one leaves the room. Shortly thereafter, the
child will begin to look for an object that has been dropped. At first, an auditory cue
when it hits the floor is necessary to locate it. Later, the child will experience success in
finding an object that was dropped from sight and landed silently. Next, the child will
progress to finding an object that has been hidden under a cloth or cup. A more
complex task is locating an object that has been wrapped inside a cloth. Success
requires persistence and memory of the object long enough to complete the three-part
unwrapping process. The next skill in this sequence is the ability to locate an object
under double layers (eg, a cube is placed under a cup and then the cup is covered with
a cloth). This is followed by the ability to locate an object after serial displacements. In
this task, an object is hidden under one cover and then changed to another one. The
younger infant always will look for it under the first cover, even though the position
change was seen. Later, he or she will become successful with this task, as long as
each successive displacement still is witnessed. Not until the end of the second year is
the child able to deduce the location of an object that is hidden without observing the
displacement.

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 Another important concept dominating this period of development is causality.
Initially, the infant accidentally discovers that his or her actions produce a certain effect
(eg, kicking the side of the crib activates a mobile overhead). The infant learns to repeat
these actions to obtain the same effects. Later, he or she will vary actions to cause a
novel effect (pulling a string to obtain the ring). The concept of causality parallels social
development in which the infant learns to manipulate the environment by crying or
smiling to obtain the desired reaction from caregivers. As the infant approaches 2 years
of age, he or she will learn that apparent unrelated actions can be combined to produce
an effect (eg, winding a key to make a toy move).

LANGUAGE DEVELOPMENT

Delays in language development are more common than delays in other

developmental domains. Parents and pediatricians generally are less familiar with
language milestones. Language is the most difficult domain to assess by observation
because infants rarely vocalize spontaneously in the clinician’s office. For this reason, it
is essential for the clinician to obtain a thorough and accurate language history. The
pediatrician should become familiar with milestone terminology and learn to give
examples (eg,“ razzing”). Between 10 and 18 months of age, word counts help in
assessing a child’s expressive skills; after 18 months of age, vocabularies increase
exponentially, and it is difficult to keep up with counts.

Language includes receptive and expressive skills. Receptive skills reflect the
ability to understand language; expressive skills reflect the ability to make thoughts,
ideas, and desires known to others. Expression of language can take several forms:
speech, gestures, sign language, writing, typing, and“ body language.” Thus, language
and speech are not synonymous. Speech is simply the vocal expression of language. A
child can have normal language and yet be unable to speak. Examples include children
who are deaf and children who have severe cerebral palsy. The child who has a hearing
impairment may use manual sign language to communicate. A child who has normal
intelligence but cannot speak because of oral-motor dysfunction related to cerebral
palsy may use a computer that is activated with a head stick. Conversely, a few children
talk but fail to use speech to communicate (eg, children who have autism). Their

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vocalizations consist of “parrot talk” or echolalia that has no communicative intent and,
thus, does not represent language.

Language development during infancy can be divided into three periods:

prespeech, naming, and word combination periods.

Prespeech Period (0 to 10 months): Receptive language is characterized by an

increasing ability to localize sounds. Sound localization is assessed by using a
noisemaker such as a bell (Fig. 7⇓ ). Expressive language consists of musical-like
vowel sounds (cooing) that are interrupted by crying when the baby has a need. At
about 3 months, the infant will begin vocalizing immediately upon hearing an adult
speak. One or two months later the infant is silent and assumes a posture that implies
he or she truly is“ listening” to the speaker. These infants make no vocalizations until
the speaker is quiet, mimic the speaker, and then quiet again when the adult speaks.
They appear to enjoy the “vocal tennis” and repeat this for several cycles. At
approximately 6 months of age, the infant adds consonants to the vowel sounds in a
repetitive fashion (babbling). Soon the infant appears to initiate conversations. When a
random vocalization (eg, “dada”) is interpreted by the parents as a real word, they show
pleasure and joy. In so doing, adults give meaning to these first “words” and reinforce
their repeated use.

Naming Period (10 to 18 months): This period is characterized by the infant’s

realization that people have names and objects have labels. It is an important turning
point in language development. The “dada” and “mama” that were vocalized randomly
have been reinforced, so the infant now begins to use them appropriately. Infants next
recognize and understand their own names and the meaning of “no.” This marks the
beginning of exponential growth in receptive language. By 12 months of age, some
infants understand as many as 100 words. They also can follow a simple command as
long as the speaker uses a gesture. Early in the second year, a gesture no longer is
needed to aid in comprehension of the command. Expressive language progresses at a
somewhat slower rate. The infant will say at least one “real” word (ie, other than mama,
dada, or a proper name) before his or her first birthday. At this time, the infant also will
begin to verbalize with sentence-like intonation and rhythm (immature jargoning). As the

17
expressive vocabulary increases, real words are added (mature jargoning). By the end
of the naming period, the infant will use approximately 25 words spontaneously.

During this period, pointing becomes important to both receptive and expressive
language skills. Pointing already has become a method of exploration within the
problem-solving domain. The infant beginning to look in the general vicinity where the
adult is pointing is a receptive language skill. This ability is facilitated by the
infantrsquo;s new realization that objects have labels. Later, the infant begins to take
part in pointing games. He or she will point first to family members, then objects, body
parts, articles of clothing, and pictures upon request. These all reflect receptive
language skills.

Pointing also is used for language expression. First, the infant points at an object
and uses the adult as a tool to retrieve the object, referred to by linguists as
protoimperative pointing. The infant first points to the object (eg, a cookie) and then
looks back and forth between the adult and the object expectantly. At a later stage, he
or she directs attention to the adult and alternately points at the adult and the desired
object while vocalizing (eg, “uh...uh”). Next, the infant uses the object as a tool to obtain
the parent’s attention (protodeclarative pointing). Protodeclarative pointing is a social
act; the parent is an active and important partner in a shared world. Rather than
acquisition of the object, the infant’s goal becomes the parent’s acknowledgment of the
interesting object. For example, when an infant hears an airplane overhead, he or she
points to it and vocalizes to get the parent to look at it. If the parent does not comply
with these initial efforts, the infant may approach the parent and turn his or her face
toward the plane in a more determined effort to obtain what is sometimes called “joint
attention.” Finally, the infant will point at an object and vocalize (“uh?”) in an effort to
obtain the proper label or name for that object from the listener. This is called “pointing
for naming.”

Word Combination Period (18 to 24 months): Typically, children begin to combine

words approximately 6 to 8 months after they say their first word. If word combinations
appear much earlier, they are likely “giant words.” Giant words are two- or three-word
combinations that the infant hears frequently, such as “Thank you,” “Stop it,” or “Let’s

18
go.” When the infant says one of these, he or she really is treating the phrase as a
polysyllabic single word. At this stage of development the infant does not use either
word separately or in novel combinations with other words.“ Holophrases” also are
beginning to appear at this time. For example, an infant may point to a mother’s keys
and say “mommy” instead of saying “keys.” In this context, the single word,“ mommy,”
has a sentence-like meaning, such as “These keys belong to mommy.” Single words
take on multiple meanings and no longer simply label an object. The infant usually does
not combine words into true phrases or sentences until he or she has acquired an
expressive vocabulary of approximately 50 words. Early word combinations are“
telegraphic” in that they do not contain function words (prepositions, pronouns, and
articles). They do, however, convey the same meaning as the more mature sentence.
For example,“ Go out,” in the context of the situation, conveys the same meaning as “I
want to go outside.” Telegraphic speech is the first stage in the child’s ability to“
grammaticize” speech, that is, to form sentences with proper morphology and syntax. At
this point in development, a stranger should be able to understand at least 50% of the
infant’s speech (intelligibility). Language blossoms after 2 years of age.

EMOTIONAL DEVELOPMENT

Emotions are present in infancy and motivate expression (pain elicits crying).
Emotion has three elements: neural processes, mental processes (feelings), and motor
expression (facial, verbal) and actions. Emotions are mediated through the limbic
system, which is responsible for receiving, interpreting, and processing emotion-
producing stimuli and then initiating and modulating emotional responses. There is
evidence that an infant can express emotion without direct cognitive mediation. An
infant who has anencephaly or hydranencephaly may show disgust at sour flavors and
interest in sweet flavors in ways very similar to a normal infant. Later, in the normal
infant, these instinct-like reactions are modified by cognition. Although emotional
feelings are constant over the life span, their causes change and become more
abstract. The infant may show disgust for a bitter taste; the older child may show
disgust for a revolting idea. Other emotions have a definite cognitive foundation. To
experience fear, the 7- to 9-month-old child must be able to shift attention, compare,

19
and recognize “familiar” from“ unfamiliar” in the development of stranger anxiety. As the
child develops, the interrelationship between emotion and cognition becomes
increasingly complex. When the child begins to associate language symbols with
emotions and memory, he or she can remember prior emotional experiences. A verbal
reminder of the event then can evoke feelings identical to those experienced previously.
Thus, language and cognition add flexibility and complexity to emotional behavior.

The expression of emotions also evolves with age and developmental

advancement. Consider this example of an emotional reaction (fear) to a stranger,
based on skill level: In addition to developmental progress, the feedback loop between
care providers and child modifies emotional expression. Social forces and cultural
factors also modulate emotional expression to produce more restrictive and controlled
facial signals. An older child may learn to modulate the expression of pain (a facial
grimace only) and appear quite stoic. Furthermore, children can learn to mask emotions
such as smiling at a disappointing gift. At early stages, however, the true emotion
typically leaks out from under the mask.

SOCIAL DEVELOPMENT

The infant is surrounded by a social network. Sensory processing is influenced

by the infant’s social needs. The infant has greater discrimination ability for social
voices) than for nonsocial (environmental noise) stimuli. There are two primary theories:
the Epigenetic Model and the Social Network Model. In the Epigenetic Model, the
mother-child relationship is considered to be all important. If this relationship is negative,
then other relationships will be poor. If it is positive, then future relationships will be
good. The Social Network Model recognizes the relative importance of the mother-child
relationship, but also recognizes the ability of other relationships to compensate for
absent or poor mother-child interactions. The devastating effect of a poor relationship
can be overcome by adequate substitutes and a supportive environment. The latter
reflects the popular concept of childhood resiliency.

Social milestones begin with bonding, which reflects the feeling of the caregiver
for the child. Attachment takes place within a few months and represents the feeling of
the infant for the caregiver. These social relationships are manifested by the evolution of

20
the smile, in which the level of stimulus required to elicit reciprocity decreases. At first,
high-pitched vocalizations and a smile from the adult are needed; later, a smile alone is
successful. When recognition of and attachment to a familiar caregiver develops, the
simple sight of this person (smiling or nonsmiling) will elicit a smile. The infant also
becomes more discriminating in producing a smile as he or she begins to differentiate
between familiar and unfamiliar faces. As the infant acquires the concept of causality,
he or she begins to use smiling to manipulate the environment and satisfy personal
needs.

Later in infancy, other social relationships are established. Several behaviors are
necessary for the development of these relationships. First, the infant must have a
concept of self-versus others. Next, he or she must be able to put self in the place of
another, that is, to show empathy. The infant must perceive a separate identity with a
different set of needs. He or she must realize the consequences of his or her
interactions on others. Empathy is critical to forming a relationship. Next the child must
be able to share, which is critical to maintaining a relationship. There are four basic
types of relationships: with acquaintances, strangers, friends, and loves. Whereas
relationships with acquaintances and strangers simply require a concept of self,
friendship and love require all three (a concept of self, empathy, and sharing). About the
same time that the child can label emotions (via language), he or she begins to think
about social interactions. A child will demonstrate recursive social thoughts, that is,
show early signs of thinking about how others behave toward him or her and how he or
she behaves toward others.Temperament, or the infant’s overall style of reacting, can
affect social relationships. The precise definition of temperament is controversial, but it
generally is believed to represent the characteristic style of a child’s emotional and
behavioral response in a variety of situations. It is determined by genetic factors but is
modified by environmental forces. Temperament shows considerable stability over time.
Thomas and Chess describe nine traits that determine whether a child will have an
“easy,”“ difficult,” or “slow-to-warm-up” temperament:

Activity level—proportions of periods of activity to inactivity

21
 Adaptability to change;Positive or negative mood;Intensity of emotional
responses;Rhythmicity of biologic functions; Persistence in the face of environmental
counterforces;Distractibility or ease of soothi;Approach versus withdrawal tendencies in
new situations.Threshold of stimulation necessary to produce a response

The Carey Infant Temperament Questionnaire often is used to evaluate these

traits formally. Approximately one third of infants will be characterized as difficult or
slow-to-warm up. The other two thirds will be classified as easy infants. The easy
infants fall into three subcategories: 1) gentle, tender, sensitive, affectionate; 2)
changeable, variable, adaptable; and 3) social, playful, happy, attention-seeking. A
child’s temperament can influence developmental testing. The child who is difficult or
slow to warm up may refuse to cooperate with test items, thereby receiving lower scores
that do not reflect his or her true abilities.

ADAPTIVE SKILL DEVELOPMENT

Adaptive skill development is influenced by the infant’s social environment, as

well as by motor and cognitive skill attainment. A child who has quadriparesis may not
be able to feed him- or herself, even with normal intelligence and a supportive social
environment.

In contrast, acquisition of self-help skills by an able-bodied infant may be delayed

in the face of mental retardation and the lack of motivation to become independent. In
spite of normal motor and cognitive skills, an infant may demonstrate delays in adaptive
skills when social support and encouragement are lacking. This is exemplified by delays
in self-feeding skills when the caregiver is overly concerned about messy spillage or
feels the need to rush mealtime. Additionally, parents may persist in dressing the older
child in an effort to rush to child care. The decision to initiate toilet training often is
influenced by both family and culture

RED FLAGS IN PSYCHOSOCIAL DEVELOPMENT

Decreased rhythmicity (eg, colic) may be an early indication of a“ difficult child.”

Delay in the appearance of a reciprocal smile may indicate an attachment problem,
which may be associated with maternal depression. In severe cases, child neglect or

22
abuse may be suspected. However, a delay in smiling also may be associated with
visual or cognitive impairment. The lack of social relationships plays a key role in the
diagnosis of autism when it is accompanied by delayed or deviant language
development and stereotypic behaviors. History and observation of an infant’s behavior
at play may alert the clinician to abnormal social relationships. The emotional status of
the parents and parenting styles may affect the infant’s development of adaptive skills.
A controlling, rejecting parenting style may be revealed in an oppositional child who
refuses to cooperate with self-care. Delays in adaptive skills also may indicate
overprotective parents or an excessive emphasis on cleanliness

LOCAL

Potential for catch-up growth among stunted children is thought to be limited after
age 2 y, particularly when they remain in poor environments. We explored the extent to
which there were improvements in height status from age 2 to 12 y in a cohort of >2,000
children from the Cebu (The Philippines) Longitudinal Health and Nutrition Survey. At
age 2 y, about 63% of sample children were stunted as defined by height-for-age (HAZ)
<−2 based on the WHO reference. Of children stunted at age 2, 30% were no longer
stunted at 8.5 y, and 32.5% were no longer stunted at 12 y. The mean increase in HAZ
among those with such improvements was 1.14 units. The likelihood that children
stunted at age 2 y would no longer be stunted at 8.5 y was estimated using logistic
regression. Low birth weight, which was associated with more severe stunting in the first
2 y of life, significantly reduced likelihood of catch-up growth in later childhood. In
contrast, children with taller mothers, who were first born, longer at birth, less severely
stunted in early infancy and those with fewer siblings were more likely to increase HAZ
from <−2 to >−2 between ages 2 and 8.5 y. Similar factors predicted the improvement in
linear growth from 8.5 to 12 y. These results suggest that there is a large potential for
catch-up growth in children into the preadolescent years.

Linear-growth retardation is a continuing health problem among children living in

poverty in developing countries. It is generally well accepted that most growth
retardation occurs during the first 2 y of life, associated primarily with high rates of
infection and inadequate nutrition related to poor weaning practices and poor dietary

23
quality. After 2–3 y of age, linear-growth rates of poor children are more similar to those
observed in well-nourished children. Thus, deficits in adult height are attributed primarily
to linear-growth retardation in infancy and early childhood (Martorell and Habicht 1986).

There is a lack of a consensus about the extent to which catch-up growth in later
childhood and adolescence reduces the height deficit incurred in early childhood. The
biological potential for catch-up growth is well illustrated in studies that evaluate
response to clinical intervention with supplementary feeding, treatment of illness or
hormone therapy (Golden 1994). Tanner (1981) advanced the general hypothesis that
when undernourished children are exposed to better environments and good nutrition,
the likelihood of catch-up is greater, with the degree of recovery depending on the
severity of growth retardation and the timing of exposures. However, the degree to
which catch-up occurs in the absence of medical or nutrition intervention is less well
documented. Martorell et al. (1994) evaluated the evidence for reversibility of stunting in
epidemiologic studies, dividing studies into those cases where children remain in the
same poor environments responsible for stunting, vs. those where the child's situation
was improved by nutrition supplementation or migration. They concluded that when
children remain in the same poor environment, the growth deficits developed in early
childhood persist into adulthood, with little catch-up growth. Relatively little is known
about the potential for catch-up growth during adolescence. Martorell et al. (1994)
suggest that catch-up may depend on whether undernutrition is also associated with
delayed maturation, which in turn could allow for a prolonged adolescent growth spurt
with greater time for recovery before skeletal growth is complete.

Conclusions about whether, how, and when catch-up occurs are based on limited
evidence. First, relatively few longitudinal studies followed children from birth to late
childhood or adulthood. Second, in the longitudinal studies that have been done, there
are limited observation points with long gaps between measurements, so that changes
in the environment and other factors that influence growth are not well documented.
Third, epidemiologic studies of catch-up growth tend to compare groups of children or
adults by their initial level of stunting (e.g., Martorell et al. 1990, Satyanarayana et al.
1989). These studies tend to show substantial tracking of stature, with groups who were

24
short as young children remaining short as older children or adults. However, with their
focus on central tendencies of the groups, they fail to identify individual children who
exhibit catch-up growth, and thus cannot contribute substantially to our understanding of
the circumstances under which catch-up occurs.

In this paper, we present evidence of catch-up growth based on a longitudinal

ecological study of a cohort of Filipino children from Metro Cebu. We focus on growth
from age 2 to 12 y, with an intermediate measurement taken at age 8.5 y. We model the
overall determinants of height increments, identify children who exhibit catch-up growth,
and identify factors associated with recovery from stunting.

The study has a number of important strengths. First, it builds on earlier work to
identify determinants of incident stunting from birth to age 2 y in the same Cebu
Longitudinal Health and Nutrition Survey (CLHNS)1 sample (Adair and Guilkey 1997).
Second, the cohort is large (>2,000), and children live in diverse urban and rural
environments. Third, we have detailed, repeated measures of socioeconomic and
ecological conditions in each household, as well as dietary intake. Finally, by identifying
individual children who recover from stunting, we can report the incidence of catch-up
growth and, using multivariate methods, report determinants of recovery from stunting.

Catch-up growth:While there is considerable clinical and epidemiologic literature

on catch-up growth, there is no standard definition of “catch-up growth.” In general, the
term refers to acceleration in growth after a period of growth retardation. The
assumption is that accelerated growth will return the individual to his or her genetically
determined growth trajectory (Ashworth and Milward 1986). However, sometimes catch-
up is used to refer to complete recovery or restoration of growth to normal levels. In
other cases, catch-up is considered to be an acceleration in growth rates which may or
may not result in stature within normal limits for age and sex. For the present analysis,
we define catch-up growth with and without reference to an external reference.
“Recovery from stunting” is defined as a HAZ-score <−2 at age 2 y, but ≥−2 at age 8.5
or 11–12 y. Use of a variable representing a change in Z-score may be problematic
because a Z-score has a different meaning at different ages (Tanner 1986). Z-scores
among older children may misclassify those whose pre-adolescent and early adolescent

25
growth pattern differs from the WHO reference population. Of concern for the present
study is the likelihood of later sexual maturation relative to the reference population, and
thus apparent inflation of the magnitude of growth retardation relative to the reference.
To avoid the use of an external reference, we also assess height increments in the two
age intervals (2 to 8.5 and 8.5 to 12 y). The increment from age 2 to 8.5 y is a slight
underestimate of the actual height increment, since the measurement at age 2 was of
recumbent length. Finally, we regress height at time t on height at time t-1, sex, and
duration of the interval from t-1 to t, and calculate residuals. Children are then grouped
according to their studentized residuals, and catch-up growth is defined as a residual >1
(14.3% of the sample). This method identifies children with greater than expected
growth, irrespective of their starting length (Esrey et al. 1990)

Results: HAZ-scores of sample children at ages 2–12 y are shown in Figure 1. The
1994 data are stratified by age in half-year intervals to show the cross-sectional
differences in height by age. There were no significant differences in earlier height
measures among children measured at different ages in 1994–95. The lower HAZ
scores of older girls most likely represent delayed maturity in the Filipinas relative to the
U.S. reference population.The prevalence of stunting in Cebu children is quite high
when judged relative to the WHO reference. Nearly two-thirds of females and about
60% of males were stunted at age 2 y. Using the Filipino national reference data and
suggested cutoff of length below the 5th percentile (Florentino et al. 1992), 15.6% of
males and 10.8% of females were “underheight,” suggesting that stunting is more
prevalent in the Cebu sample than in the country as a whole.

26
 OBJECTIVES

We the students of BSN-12F Group 24 are conducting a study about Growth and
Development towards our patient by attaining sufficient information which could help us;

1. Know the patient’s family profile, past health history, current health history, and
physical examination.

2. Review pathophysiology of Growth and Development of a Toddler.

3. Describe the physical and emotional changes they undergo as they grow up.

4. Discuss the various beliefs and values of their society with regard to human
growth and development.

5. Obtain factual information about the human reproductive process.

27
 GLOSSARY OF TERMS

GROWTH - is the progressive increase in the size of a child or parts of a child

DEVELOPMENT- is progressive acquisition of various skills (abilities) such as head

support, speaking, learning, expressing the feelings and relating with other people.

TODDLER- is a child 12 to 36 months old. The toddler years are a time of great
cognitive, emotional and social development. The word is derived from "to toddle",
which means to walk unsteadily, like a child of this age.

INTUBATION-, is the placement of a flexible plastic tube into the trachea (windpipe) to
maintain an open airway or to serve as a conduit through which to administer certain
drugs.

PSYCHOLOGY- is the scientific study of the mind and behavior, according to the
American Psychological Association. Psychology is a multifaceted discipline and
includes many sub-fields of study such areas as human development, sports, health,
clinical, social behavior and cognitive processes.

IMMUNIZATION- is the process whereby a person is made immune or resistant to an

infectious disease, typically by the administration of a vaccine. Vaccines stimulate the
body's own immune system to protect the person against subsequent infection or
disease

28
 SIGNIFICANCE OF THE STUDY

Findings of the study can be beneficial to the:

Administration:

This study is beneficial to the administration so that they will have a basis for the
future implementation of programs that will help the situations of students having clinical
exposure.

Parents:

This study is beneficial for clients, especially those clients that has encounter this
sickness. It will help the clients to be more responsible and to have enough knowledge
on taking good care of their children.

Students:

This study will serve as the basis in improving and enhancing the skills of each of
every student nurse. It will provide information about mother and child management.

Davao Doctors College:

This study will improve the school in the development of nursing education. This
study will foster new ways of enhancing knowledge, skills and attitude, thus preparing
globally-competitive nurses in the future. This study will also help in the advancement of
school management, clinical leadership and teaching-evaluation approach.

29
 CHAPTER II

Patient’s profile (comprehensive assessment)

Patient’s Profile

Name: Patient X

Age: 1 year old and 2 months

Sex: Female

Address: Agdao, Davao City

Birthplace: Davao City

Nationality: Filipino

Religion: Roman Catholic

Civil Status: Child

Birthday: Sept 1, 2018

Allergies: NONE

Date of Admission: October 22, 2019

Chief Complaint: Fever

Final Diagnosis: Lower Respiratory Tract Infection

30
A.Present Medical history

Patient x prior to admission for 4 Days of onset of fever and cough.

B. Past medical history

Patient x confined last 5months Because of fever and cough.

C.Family history

Paternal Grandfather- Unknown

Paternal Grandmother- Unknown

Maternal Grandmother- Healthy with no known medical problems

Maternal Grandfather- Unknown

Mother – Healthy with no known medical problems

Father - Unknown

There is no family history of diabetes, seizures, cancer, heart disease, hypertension or

sickle cell on the maternal side. However, very little is known about the paternal side.

D. Maternal and Prenatal History

Maternal –NOT APPLICABLE

Prenatal – NOT APPLICABLE

31
E. Developmental History

Theorist Age Sex Patient’s descripton

Erik Erikson’s Birth to 12- 18 For both male and I observed that she
Psychosocial Theory months female depends primarily to
(Trust vs. Mistrust her mother to feed
stage) her. Yet there were
times she would
respond when her
grandmother and dad
gives her food. I have
seen that she is most
calm when
breastfeeding. I
sometimes tried to
make funny faces and
she smiled once in a
while.

Jean Piaget’s For both male and I noticed that she

Cognitive Birth to age 2 female always watched her
Development favorite cartoon
(Sensorimotor Stage) movie and know what
button to press so
she can hear the
sound. She could
immediately
recognize a syringe
and cries. She always

32
 tried to reach out the
thermometer
everytime I finished
taking her
temperature.

Lawrence Kohlberg’s For both male and

Moral Development For children female I observed that the
(Pre- Conventional mother could not
Level) immediately make her
daughter stop crying
even if she would
mention scary things
that might shop up if
she did not stop.
F. NUTRITIONAL HISTORY

A. Breast or bottle fed, types of formula, frequency and amount, reasons for any
changes in formula

B. Solids - when introduced, problems created by specific types

C. Fluoride use

G. IMMUNIZATION

According to her mother, she said that her daughter only had BCG vaccine.

33
H. PHYSICAL EXAMINATION (Cephalo-caudal)

Body parts Technique used findings

(area assessed)
Skin
Color Inspection Fair-skinned, no
discoloration and
Texture Palpation hyperpigmentations
Temperature Palpation smooth, soft warm to touch
Moisture Palpation moist due to perspiration

Nails
Color of nailbed Inspection Pink and clean
Texture Palpation smooth
Shape Inspection convex curvature
Nail base Inspection firm

Hair
 Color Inspection Black
 Distribution Inspection Evenly distributed
 Moisture Inspection Not excessively dry or oily
 texture Inspection Fine, silky, resilient

Eyes
 eyebrows Inspection Symmetrically aligned,
equal movement
 eyelashes Inspection Slightly curved upward
 eyelids Inspection Smooth, pink, close
symmetrically
 ability to blink Inspection Blinks voluntarily and

34
 bilaterally

 ocular movement Inspection Eyes move freely

 size Inspection Medium
 texture Palpation Mobile, firm, not tender
 conjunctiva Inspection transparent with light color,
shiny and smooth, no
lesions
 cornea Inspection
Clear, shiny , smooth,
transparent
 pupils Inspection
Equal size, round and
constricts briskly, equally
reactive light
Eyes
 eyebrows Inspection Symmetrically aligned,
equal movement
 eyelashes Inspection Slightly curved upward
 eyelids Inspection Smooth, pink, close
symmetrically
 ability to blink Inspection Blinks voluntarily and
bilaterally

 ocular movement Inspection Eyes move freely

 size Inspection Medium
 texture Palpation Mobile, firm, not tender
 conjunctiva Inspection transparent with light color,
shiny and smooth, no
lesions
 cornea Inspection

35
 Clear, shiny , smooth,
transparent
 pupils Inspection
Equal size, round and
constricts briskly, equally
reactive light
Nose
 symmetry, shape, Inspection symmetrical ,
size and color smooth and fair
 mucosa color Inspection pinkish
 nasal septum Inspection oval and symmetrical
 nasal discharge Inspection nares with clear
 sinuses Palpation discharges
not tender
Mouth Inspection Pinkish, symmetrical,
▪ lips smooth and moist
▪ gums Inspection Pinkish and moist
▪ buccal mucosa Inspection Pinkish, soft, moist
▪ tongue Inspection Pinkish, small, symmetrical
▪ uvula Inspection at the midline
▪ teeth Inspection 6 milk teeth

Heart
 Heart rate Auscultation 140 bpm
 Heart sound Auscultation clear

Thorax and Lungs

 Symmetry Inspection Symmetrical
 Respiratory rate Inspection 26 bpm
 Breathing pattern Inspection Irregular, with effort
 Lung/breath sounds Auscultation Ronchi

36
Abdomen
 Contour Inspection Flat
 Texture Palpation Smooth
 Frequency and Auscultation Soft gurgling sound
character
Upper Extremities
 Skin color Inspection Fair
 Size Inspection Equal and appropriate for
her body
 Symmetry Inspection symmetrical

Lower Extremities
 Skin color Inspection Fair
 Size Inspection Equal and appropriate for
her body
 Symmetry Inspection symmetrical
Neurologic
 Level of Interview Responds quickly when
consciousness name was being called
Interview Makes eye contact, normal
 Behavior and behavior for a toddler
appearance Interview Irritable
 Mood Interview Likes to cuddle to her
 Mannerism and mother
actions

37
 CHAPTER III

ANATOMY AND PHYSIOLOGY

Children are not small adults. Pediatric patients vary considerably and include
the following groups:

Neonates – a baby within 44 weeks of age from the date of conception

Infants – a child of up to 12 months of age

Child – 1 to 12 years

Adolescent – 13 to 16 years

The differences between pediatric and adult anesthetic practice are reduced as
the patients become older.

The important anatomical and physiological differences will be considered below

followed by a discussion of how these will affect anesthetic practice.

A. Airway and Respiratory System

•They have a large head, short neck and a prominent occiput.

•The tongue is relatively large.

•The larynx is high and anterior, at the level of C3 - C4. The epiglottis is long, stiff and
U-shaped. It flops posteriorly. The ‘sniffing the morning air’ position will not help bag
mask ventilation or to visualize the glottis. The head needs to be in a neutral position.
ƒ Neonates preferentially breathe through their nose. Their narrow nasal passages are
easily blocked by secretions and may be damaged by a nasogastric tube or a nasally
placed endotracheal tube. 50% of airway resistance is from the nasal passages.

•The airway is funnel shaped and narrowest at the level of the cricoid cartilage. Here,
the epithelium is loosely bound to the underlying tissue. Trauma to the airway easily
results in edema. One millimeter of edema can narrow a baby’s airway by 60%.

38
•An endotracheal tube must be inserted to the correct length to sit at least 1cm above
the carina and be taped securely so as to prevent tube dislodgement with head
movement, or an endobronchial intubation.

•The neonate and infant have limited respiratory reserve.

•Horizontal ribs prevent the ‘bucket handle’ action seen in adult breathing and limit an
increase in tidal volume. Ventilation is primarily diaphragmatic. Bulky abdominal organs
or a stomach filled with gases from poor bag mask ventilation can impinge on the
contents of the chest and splint the diaphragm, reducing the ability to ventilate
adequately.

•The chest wall is significantly more compliant than that of an adult. Subsequently, the
functional residual capacity (FRC) is relatively low. FRC decreases with apnea and
anesthesia causing lung collapse.

•Minute ventilation is rate dependent as there is little means to increase tidal volume.

•The closing volume is larger than the FRC until 6-8 years of age. This causes an
increased tendency for airway closure at end expiration. Thus, neonates and infants
generally need IPPV during anesthesia and would benefit from a higher respiratory rate
and the use of PEEP. CPAP during spontaneous ventilation improves oxygenation and
decreases the work of breathing.

•Work of respiration may be 15% of oxygen consumption.

• Muscles of ventilation are easily subject to fatigue due to low percentage of Type I
muscle fibers in the diaphragm. This number increases to the adult level over the first
year of life.

•The alveoli are thick walled at birth. There is only 10% of the total number of alveoli
found in adults. The alveoli clusters develop over the first 8 years of life.

•Apneas are common post operatively in premature infants. Apneas are significant if
they last longer than 15 seconds and are associated with desaturation or bradycardia.
Caffeine 10-20 mg/kg oral or IV given peri-operatively may be useful.

39
•RR = 24 – age/2

•Spontaneous ventilation TV = 6-8 ml/kg; IPPV TV = 7-10ml/kg

•Physiological dead space = 30% and is increased by anesthetic equipment.

B. Cardiovascular System

•In neonates the myocardium is less contractile causing the ventricles to be less
compliant and less able to generate tension during contraction. This limits the size of
the stroke volume. Cardiac output is therefore rate dependent. The infant behaves as
with a fixed cardiac output state. Vagal parasympathetic tone is the most dominant,
which makes neonates and infants more prone to bradycardias.

•Bradycardia is associated with reduced cardiac output. Bradycardia associated with

hypoxia should be treated with oxygen and ventilation initially. External cardiac
compression will be required in the neonate with a heart rate of 60 beats per minute or
less, or 60-80 beats per minute with adequate ventilation.

• Cardiac output is 300-400 ml/kg/min at birth and 200 ml/kg/min within a few months.

• Sinus arrhythmia is common in children and all other irregular rhythms are abnormal.

Normal Heart Rates (beats/min) and Systolic Blood Pressure (mmHg)

Age Average Range MeanSBP

Preterm 130 120-170 40-55

Newborn 120 100-170 50-90

1-11 months 120 80-160 85-105

2 years 110 80-130 95-105

4 years 100 80-120 95-110

6 years 100 75-115 95-110

8 years 90 70-110 95-110

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10 years 90 70-110 100-120

14 years boy 80 60-100 110-130

Girl 85 65-105 110-130

16 years boy 75 55-95 110-130

Girl 80 60-100 110-130

•The patent ductus contracts in the first few days of life and will fibroses within 2-4
weeks. Closure of the foramen ovule is pressure dependent and closes in the first day
of life but it may reopen within the next 5 years. The neonatal pulmonary vasculature
reacts to the rise in Pa02 and pH and the fall in PaCO2 at birth. However, with
alterations in pressure and in response to hypoxia and acidosis, reversion to the
transitional circulation may occur in the first few weeks after birth.

Normal Blood Volume

Age Blood volume

New-born 85 –90 ml/kg
6 weeks to 2 years 85 ml/kg
2 years to puberty 80 ml/kg

C. Renal System

•Renal blood flow and glomerular filtration are low in the first 2 years of life due to high
renal vascular resistance. Tubular function is immature until 8months, so infants are
unable to excrete a large sodium load.

•Dehydration is poorly tolerated. Premature infants have increased insensible losses as

that have a large surface area large surface area relative to weight. There is a larger
proportion of extra cellular fluid in children (40% body weight as compared to 20% in the
adult).

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•Urine output 1-2 ml/kg/hr

D. Hepatic System

•Liver function is initially immature with decreased function of hepatic enzymes.

Barbiturates and opioids for example have a longer duration of action due to the slower
metabolism.

E. Glucose Metabolism

•Hypoglycemia is common in the stressed neonate and glucose levels should be

monitored regularly. Glycogen stores are located in the liver and myocardium.
Neurological damage may result from hypoglycemia so an infusion of 10% glucose may
be used to prevent this. Infants and older children maintain blood glucose better and
rarely need glucose infusions.

•Hyperglycemia is usually iatrogenic.

F. Hematology

•At birth, 70-90% of the hemoglobin molecules are HbF. Within 3 months the levels of
HbF drop to around 5% and HbA predominates. A hemoglobin level in a newborn will be
around 18-20 g/dl which is a hematocrit of about 0.6. The hemoglobin levels drop over
3-6 months to 9-12 g/dl as the increase in circulating volume increases more rapidly the
bone marrow function.

•HbF combines more readily with oxygen but is then released less readily as there is
less 2,3-DPG. HbF is protective against red cell sickling.

•The 02/Hb dissociation curve shifts to the right as levels of HbA and 2,3-DPG rise.

•The vitamin K dependent clotting factors (II, VII, IX, X) and platelet function are
deficient in the first few months. Vitamin K is given at birth to prevent hemorrhagic
disease of the newborn.

•Transfusion is generally recommended when 15% of the circulating blood volume has
been lost.

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G. Temperature Control

•Babies and infants have a large surface area to weight ratio with minimal subcutaneous
fat. They have poorly developed shivering, sweating and vasoconstriction mechanisms.

•Brown fat (located in small amounts around the scapulae, the mediastinum, the
kidneys and adrenal glands) metabolism is required for non-shivering thermogenesis. It
comprises 2-6% of neonatal body weight. More oxygen is required for the metabolism of
these brown fat stores.

•Heat lost during anesthesia is mostly via radiation but may also be lost by conduction,
convection and evaporation. The optimal ambient temperature to prevent heat loss is
34ºC for the premature infant, 32ºC for neonates and 28ºC in adolescents and adults.

•Low body temperature causes respiratory depression, acidosis, decreased cardiac

output, increases the duration of action of drugs, decreases platelet function and
increases the risk of infection.

H. Central Nervous System

•Neonates can appreciate pain and this is associated with increased heart rate, blood
pressure and a neuro-endocrine response.

•Narcotics depress the ventilation response to a rise in PaC02.

•The blood brain barrier is poorly formed. Drugs such as barbiturates, opioids,
antibiotics and bilirubin cross the blood brain barrier easily causing a prolonged and
variable duration of action.

•The cerebral vessels in the preterm infant are thin walled, fragile. They are prone to
intraventricular hemorrhages. The risk is increased with hypoxia, hypercarbia,
hypernatremia, low hematocrit, awake airway manipulations, rapid bicarbonate
administration and fluctuations in blood pressure and cerebral blood flow. Cerebral
autoregulation is present and functional from birth.

I. Psychology

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•Infants less than 6 months of age are not usually upset by separation from their parents
and will more readily accept a stranger.

•Children up to 4 years of age are upset by the separation from their parents and the
unfamiliar people and surroundings. It is difficult to rationalize with a child of this age.
The behavior of this group is more unpredictable.

•School age children are more upset by the surgical procedure, its mutilating effects and
the possibility of pain.

•Adolescents fear narcosis and pain, the loss of control and the possibility of not being
able to cope with the illness. This is worsened by long periods of hospitalization.

•Parental anxiety is readily perceived and reacted on by the child.

•Practicalities for Anaesthetizing Children

J. Pre-operative Visit

Use this time to develop rapport and trust with the child and parent. Address the
child first and then include the parents in discussion. Address the queries and fears of
the child as well as those of the parent. Explain the planned approach to induction so
both parent and child know what to expect.

It is important to take a medical and anesthetic history. Any previous problems

with anesthetics including family history, Allergies, Previous medical problems including
congenital anomalies, Recent respiratory illness, Current medications

•Recent immunizations. Fasting times & Presence of loose teeth.

Conduct a physical examination as appropriate concentrating on the airway and

cardiorespiratory systems.

Children must be weighed. All drug doses relate to body weight. Weight (kg) can
be estimated by: (age + 4) x 2. This is less accurate over 10 years.

Investigations may occasionally be necessary: Hemoglobin – large expected

blood loss, premature infants, systemic disease, congenital heart disease Electrolytes –
renal or metabolic disease, intravenous fluids, dehydration CXR – active respiratory

44
disease, scoliosis, congenital heart disease Discuss post-operative pain management.
If suppository medications are to be used, consent should be obtained from the parent
and the child if they are able to understand.

K. Pre-operative Fasting

6 hours for solids and milk if greater than 12 months of age 4 hours for breast
milk and formula feeds if less than 12 months of age 2 hours for unlimited clear fluids
(as this decreases gastric acidity and volume) There is an increased incidence of
nausea and vomiting with long fasting periods.

L. Pre-medication

In our institution, sedative pre-medication is infrequently used. Psychological

preparation and enlisting the help of the parents may decrease the need for sedative
pre-medication.

Sedation has a significant failure rate, tastes bad, increases time spent in
recovery and delays discharge for day stay procedures. However, an appropriately
chosen drug, timed correctly can produce a calm or cooperative child.

We most commonly use analgesic pre-medication drugs such as paracetamol,

ibuprofen or codeine phosphate given more than a half hour pre-operatively. EMLA or
amethocaine cream is applied to identifiable veins on those children for whom an
intravenous induction is planned. Allergy is possible to both these topical anesthetic
agents.

The following sedative medications may be useful:

• Midazolam 0.5 mg/kg with a maximum of 15 mg given orally 15-30 minutes

preoperatively. It has a variable result and can produce a very unpleasant excitatory
phase. Timing is important for best effect. A sweetener may be necessary.

• Chloral hydrate 50 mg/kg orally to a maximum of 1g. This also can produce an
unpleasant excitatory phase and has a bitter taste. It is also used for sedation.

• Ketamine 3-8 mg/kg orally 30-60 minutes pre-operatively.

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• Temazepam 0.5-1 mg/kg orally for older children 1 hour pre-operatively.

• Clonidine 2-4mcg/kg orally. It may cause hypotension.

Beware narcotics in infancy because of apnea.

Sedation should be used cautiously in those children with airway problems and
should be avoided altogether in neurosurgical patients especially if they have raised
intracranial pressure.

M. Preparation for Anesthesia

A parent may join their child at the time of induction. It is not compulsory but can
be useful in many instances. There must be a member of staff available to accompany
the parent from the anesthetic room after induction. It must be remembered that being
present at induction can be very stressful for the parent.

Warm the theatre and prepare any warming devices. Keeping children warm can
be a simple thing to do to improve post-operative wellbeing and outcomes. Use
bandages or cotton undercast padding to wrap the limbs and head. Plastic can also be
useful to prevent radiant heat loss.

Prepare emergency drugs such as atropine and suxamethonium in a diluted

concentration that you are familiar with to make dosing easy if an emergency should
arise.

If you do not give anesthetics to children regularly, calculate and write down the
doses of the drugs you may use appropriate for the patient’s weight.

Have your equipment ready and checked. Oropharyngeal airway, Face masks,
Laryngeal mask, Endotracheal tube, Laryngoscope and blades, and Breathing circuit (T
piece)

• Monitoring

Induction of Anesthesia

An inhalational induction can be an excellent technique for the child that fears
needles or has difficult venous access. However, it is a two person technique. A skilled

46
assistant will need to maintain the airway in the asleep child while intravenous access is
obtained. If this help is unavailable, intravenous inductions should be carried out. A
correctly sized oropharyngeal airway may be used. Choose one that is the same length
as that from the corner of the mouth to the angle of the jaw. Halothane and sevoflurane
are the agents of choice for gaseous induction.

Halothane has a slightly sweet smell and is well tolerated. Induction is

moderately slow but the rate is increased with the addition of 50-65% nitrous oxide.
Halothane has a slower offset and longer duration of action as it is more soluble.
Arrhythmias are more likely to occur. Halothane production is gradually being
discontinued in many places.

Sevoflurane is non-irritant and has a more rapid onset and offset of action as it is
less soluble. A concentration of 8% can be used initially or it can be wound up
gradually. Nitrous oxide use increases the rate and depth of anesthesia obtained. It has
improved hemodynamic stability. MAC values are 3.3 in infants, 2.5 in children and 1.7
in adults. Use is associated with emergence delirium.

The best sites for intravenous access are: Back of the hand Inner wrist Long
saphenous vein Other veins on the dorsum of the foot Cubital fossa veins are difficult
to find in infants and tissue easily at this site Elastoplast, although not sterile, provides a
secure means of fixation.

Intravenous induction can be undertaken with Propofol, thiopentone or ketamine.

Preoxygenation for a rapid sequence induction can be difficult in small children and
should be undertaken if able.

Intubation

• Straight Magill blades are useful in neonates and infants. A size 0 blade is best in
babies less than 4 kg. A curved blade is usually easier once the child is 6-10 kg.

• Uncuffed tubes are used until 8-10 years of age.

• A small leak should be present. The leak is too large if it compromises

ventilation.

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• Tube size = age/4 + 4.5 is generally a better fit than age/4 + 4 up to 10 years

• Tube length in cm = age/2 +12 (or ID x 3 for an oral ETT and add 2cm for a
nasal tube is easier to remember). This is only a guide and the tube length will always
need to be checked clinically.

• 1 LMA up to 5 kg; 1.5 LMA 5-10 kg; 2 LMA 10-20 kg; LMA 2.5 20 – 30 kg; LMA 3
for over 30 kg.

• Preformed RAE tubes may be too long.

• Secure the endotracheal tube with 1cm wide Elastoplast, ensuring that the tape
wraps about the tube and at least one tape is fixed to the less mobile maxilla. Re-check
tube length at the time of taping.

Maintenance

• Add regional analgesia where necessary. Beware intravenous narcotics in

infancy especially ex-premature infants and neonates. Use intravenous fluids for cases
with expected blood loss, intra-abdominal, or those taking longer than 30 minutes.
Extubating laryngospasm tends to occur less frequently if the child is fully awake at the
time of extubating. You may need to be with a child in recovery until fully awake if the
recovery staff are inexperienced with children.

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 CHAPTER IV-RESULTS, ANALYSIS AND JUSTIFICATION

A.COURSE IN THE WARD

On October 22, 2019, Patient X was admitted to Metro Davao Medical And
Research Center due to fever and cough. Four days before admission, there is an
onset of fever and cough.

On the day of admission patient was noted to be breathing faster and not
drinking. The patient’s past medical history revealed admission last 5 months with the
same compliant no history of diarrhea, abdominal pain, or other symptoms, nor any
significant travel history or exposure to sick contact. There was family history of sever
cough due to smoking.

On exam, she was he was tachypneic and in mild respiratory distress. On arrival
to the admitting hospital, the vital signs were: temperature 100.6°F, heart rate of 196
beats per minute and respiratory rate of 82 breaths per minute. Her oxygen saturations
were 96% to 98% on room air. Overall, she was alert and interactive and easily
consoled by her mother. She did appear to be in mild respiratory distress as evidenced
by her tachypnea, in addition to mild intercostal retractions, intermittent grunting and
nasal flaring. There was good air movement heard throughout the right lung fields and
left upper fields. Decreased breath sounds and scattered crackles were heard in the left
base. A chest X-ray and computerized tomography (CT) scan of the chest revealed
possible of pneumonia.

She received Disudrin and Biaxin orally. She remained in the hospital and still
under treatment.

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B.LABORATORYFINDINGS

WBC RESULTS REFERENCE UNIT

RANGE

Leukocyte count H 21.87 4.00 – 11.00 ×10^9/L

Erythrocyte 4.22 3.8 – 5.4 ×10^R/L
Hemoglobin 188 115 – 148 g/L
Hematocrit L 0.32 0.38 – 0.44 FL
MCV L 74.9 77 – 95 Pg
MCH 28 3 %
MCHC H 37.3 32 – 36 %
RDW-CV 13.9 11.0 – 16.0 ×10^9/L

Platelet Count 256 150 – 400

DIFFERENT
COUNT

Neutrophils L 0.18 0.40 – 0.48

Lymphocyts H 0.64 0.40 – 0.48

Monocyts H 0.18 0.05 – 0.00

Eosonophils L 0.00 0.02 – 0.04

Basophils 0.00 0.00 – 0.05

50
URINALYSIS RESULT

COLOR YELLOW

CHARACTER CLEAR

REACTION 6 split

Sp. GRAVITY 1.010

ALBUMIN Negative (-)

SUGAR Negative (-)

WBC 2-4/pf

RBC 0-2

EPITHELIAL CELLS (+)

MUCOUS ++

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 CHAPTER V

SUMMARY

Summary for Growth and Development for Toddlers Your child's rapid brain
development between the ages of 12 and 24 months causes amazing changes to
happen—such as talking, walking, and remembering—as he or she enters the toddler
years. The changes that happen in this period are often grouped into five areas:

• Physical growth. Healthy growth is different for every child, and your child will grow at
his or her own pace. Your child will continue to get new teeth and the first molars will
appear.

• Cognitive development. This is your child's ability to think, learn, and remember. Your
child will start to remember recent events and actions, understand symbols, imitate,
imagine, and pretend.

• Emotional and social development. Toddlers form strong emotional attachments and
often feel uneasy when they are separated from their loved ones. Around the same
time, toddlers typically want to do things on their own or according to their own wishes.
This sets the stage for conflict, confusion, and occasional breakdowns.

• Language development. At 15 to 18 months, a typical toddler understands 10 times

more words than he or she can speak. By the second birthday, most toddlers can say at
least 50 words.

• Sensory and motor development. Motor skills develop as your child's muscles and
nerves work together. Toddlers gain control and coordination and become steady
walkers. Climbing, running, and jumping soon follow. Why are routine medical visits
needed? During a routine check-up, the doctor examines your child to find out whether
he or she is growing as expected. In some areas, your child may see a public health
nurse for routine check-ups and immunizations. Your child will get any needed
immunizations, and the health professional will ask you questions about the new things
your child is doing, such as saying any words or walking. The health professional may

58
also check your child for signs of developmental problems such as autism. Schedule
routine check-ups for your child. Talk to your child's doctor or public health nurse about
when to make these appointments. When should I be concerned about my child's
growth and development? Talk to your doctor if your child is not reaching normal growth
and development milestones. But keep in mind that every child develops at a different
pace. A child who is slow to reach milestones in one area, such as talking, may be
ahead in another area, such as walking. Usually it is of more concern when a child
reaches developmental milestones but then loses those abilities. See your doctor if your
child makes repetitive motions or odd movements or has not bonded well with others,
especially caregivers. Also, watch for signs of hearing problems, such as not reacting to
people or loud noises. Do not hesitate to talk to your doctor anytime you have concerns
about your child, even if you are not sure exactly what worries you. How can I help my
child during this period? You can help your child grow and develop by understanding a
toddler's need for independence and allowing safe exploration. It helps your child
become confident in trying new skills when you are patient and provide unconditional
love. Also, recognize that your child can be easily overwhelmed by all the new things he
or she is seeing, hearing, learning, and doing. Help your child to get plenty of rest and
quiet time. Schedule routine checkups to keep track of your child's growth, development
and overall well-being. Present Medical History Patient Meisha Indoy prior to admission
for 4 Days of onset of fever and cough Present CBC results: Leukocyte count is High,
Hematoent Low, MCU low, UCHC high Neutrophils, Lymphocytes high, Monocytes
High, Eosinophils Low: X-ray result compatible to pneumonia. Past-medical History
Patient Meisha Indoy Confined last 5months Because of fever and cough.

59
 CONCLUSION

Between ages 2 to 7 years, young children continue to grow taller as their bodies
take on more adult proportions. They gain the ability to run and to climb stairs
independently, as well as to cut with scissors and to grip a writing tool. Cognitively,
young children learn how to think symbolically, which leads to make-believe play, and
their language explodes and matures. Emotionally, children learn how to express their
own feelings and to feel reflective empathy. Socially, they begin to cultivate
relationships with peers as well as deepen family relationships. Morally, they begin to
understand "right" versus "wrong," and to understand they have the choice about which
way to go. Sexually, young children continue to form their gender identity and begin to
understand what it means to be male or female. Beyond just understanding how young
children are growing and developing during these early years, parents also need
practical, everyday knowledge on how to care for their children and how to meet their
needs.

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 RECOMMENDATION

We recommend that children under this stage be properly guided and motivated
to further develop their cognitive development. Children under this stage can easily be
influenced by society and environment. The school and home play an important role in a
child’s development. Thus, a healthy environment will develop a healthy mind and
emotion of a child. On the contrary, a negative environment can greatly affect the child’s
upbringing and decisions. In addition, the exposure of children to extra-curricular
activities other than academics like sports enhances their social maturity and critical
thinking of children under this stage. With the right exposure, the child will be ready to
face the other challenges of life, will develop the sense of making the right decisions
and be ready in solving problems that may arise in the future.

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 BIBLIOGRAPHY

1. Knobloch H, Pasamanick B. Gesell and Amatruda’s developmental diagnosis.

New York: Harper & Row, 1974.

2. Lowrey GH. Growth and development of children. Chicago: Year Book Medical
Publishers, 1978.

3. Tanner JM. Growth and adolescence. 2nd ed. Oxford: Blackwell, 1962.

4. Tanner JM, Whitehouse RH, Takaishi M. Standards from birth to maturity for height,
weight, height velocity. And weight velocity: British children, 1965. Arch Dis Childh.
1966;41:613 [PMC free article] [PubMed]

5. Wrtzel NC. In:Glasser O, ed. Medical physics. Chicago: Year Book Medical
Publisher, 1944.

6. Macfarlane F. Paediatric anatomy and physiology and the basis of peadiatric

anesthesia. Brisbane Australia: Mater Children’s Hospital, 1995.

62