Theme 1: AGE PERIODS

Сhildren grow and develop in response to a predetermined plan that governs the physical and, to
some extent, the behavioral changes continually taking place in their bodies and minds. Growth and
development are complex processes involving numerous components that are subject to a wide variety
of influences. All facets of the child's body, mind, and personality develop simultaneously, although
not independently, and emerge at varying rates and sequences.
Physical growth begins at the time of conception; behavior and personality do not develop until
after birth. Each aspect of development, such as the organ systems and personality components, has a
timetable for growth, maturation, or elaboration. Because of the dynamic, ever-changing nature of the
developmental process, a condition or behavior that is normal at one age is considered to be abnormal
if it persists into subsequent stages of development.
Growth and Development
Human beings begin their existence with a physical, biochemical, and mental potential that is
contained in the genes they receive from each of their parents and that determines their ultimate
developmental capacity. Equally influential in shaping the individual throughout a lifetime is the
environment, which is neither constant nor dependable. At the present time hereditary factors cannot
be altered, but the environment is subject to varying degrees of manipulation.

FOUNDATIONS OF GROWTH AND DEVELOPMENT

Growth and development, usually referred to as a unit, expresses the sum of the numerous changes
that take place during the lifetime of an individual. The entire course is a dynamic process that
encompasses several interrelated dimensions.
Growth implies a change in quantity and results when cells divide and synthesize new proteins.
This increase in number and size of cells is reflected in increased size and weight of the whole or any
of its parts.
Maturation, which literally means to ripen, is described as aging or as an increase in competence
and adaptability. It is usually used to describe a qualitative change, that is, a change in the complexity
of a structure that makes it possible for that structure to begin functioning or to function at a higher
level. Sometimes maturation designates the unfolding of traits inherent in the organism.
Differentiation is primarily a biologic description of the processes by which early cells and
structures are systematically modified and altered to achieve specific and characteristic physical and
chemical properties, although it is sometimes used to describe one of the trends in development—
mass to specific.
Development is a gradual growth and expansion. It too involves a change, in this instance from a
lower to a more advanced stage of complexity. Development is the emerging and expanding of the
individual's capacities through growth, maturation, and learning to provide progressively greater
facility in functioning.
All of these processes are interrelated. Although they are simultaneous, ongoing processes, none
occurs apart from the others. The child's body becomes larger and more complex; the personality
simultaneously expands in scope and complexity. Very simply, growth can be viewed as a quantitative
change, and development as a qualitative change. Children "grow" by maintaining a positive balance
of increase over loss in size; they "grow up" by maturing in structure and function.
Stages of Growth and Development
Most authorities in the field of child development conveniently categorize child growth and
behavior into approximate age stages or in terms that describe the features of an age-group. The age
ranges of these stages are admittedly arbitrary, and since they do not take into account individual
differences, they cannot be applied to all children with any degree of precision. However, this
categorization affords a convenient means to describe the characteristics associated with the majority
of children at periods when distinctive developmental changes appear and specific developmental tasks
( a set of skills and competencies peculiar to each developmental stage that children must accomplish
or master in order to deal effectively with their environment) must be accomplished. It is also
significant for nurses to know that there are characteristic health problems peculiar to each major

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phase of development. The sequence of descriptive age periods and subperiods that are used here and
elaborated in subsequent chapters include:
Prenatal period: conception to birth
EMBRYONIC: conception to 8 weeks
FETAL: 8 to 40 weeks (birth)
A rapid growth rate and total dependency make this one of the most crucial periods in the
developmental process. The relationship between maternal health and certain manifestations in the
newborn emphasizes the importance of adequate prenatal care to the health and well-being of the
infant.
Infancy period: birth to 12 or 18 months
NEONATAL: birth to 28 days
INFANCY: 1 to approximately 12 months. The infancy period is one of rapid motor, cognitive, and
social development. Through mutuality with the caregiver (mother), the infant establishes a basic trust
in the world and the foundation for future interpersonal relationships. The critical first month of life,
although part of the infancy period, is often differentiated from the remainder because of the major
physical adjustments to extrauterine existence and the psychologic adjustment of the mother.
Early childhood: 1 to 6 years
TODDLER: 1 to 3 years
PRESCHOOL: 3 to 6 years
This period, which extends from the time children attain upright locomotion until they enter school,
is characterized by intense activity and discovery. It is a time of marked physical and personality
development. Motor development advances steadily. Children at this age acquire language and wider
social relationships, learn role standards, gain self-control and mastery, develop increasing awareness
of dependence and independence, and begin to develop a self-concept.
Middle childhood: 6 to 11 or 12 years. Frequently referred to as the "school age," this period of
development is one in which the child is directed away from the family group and is centered around
the wider world of peer relationships. There is steady advancement in physical, mental, and social
development with emphasis on developing skill competencies. Social cooperation and early moral
development take on more importance with relevance for later life stages. This is critical period in the
development of a self-concept.
Later childhood: 11 to 19 years
PREPUBERTAL: 10 to 13 years
ADOLESCENCE: 13 to approximately 18 years
The tumultuous period of rapid maturation and change known as adolescence is considered to be a
transitional period that begins at the onset of puberty and extends to the point of entry into the adult
world—usually high school graduation. Biologic and personality maturation are accompanied by
physical and emotional turmoil, and there is redefining of the self-concept. In the late adolescent
period the child begins to internalize all previously learned values and to focus on an individual, rather
than a group, identity.
Prenatal Influences on Health
The period from conception to birth is the most mysterious and least known phase of the life cycle.
It is the period when the fewest outside demands are placed on the organism, but at the same time it is
fraught with dangers that may have lifelong consequences. Recognition of the tremendous importance
of this period of rapid growth and change has focused interest on fetal development, the relationship
between prenatal events and infant health, and the factors that influence the well-being of the
individual during this and subsequent stages of life.
PRENATAL DEVELOPMENT
When they begin their existence, human beings bear no resemblance to the complex organisms into
which they will develop. In fact, during the very early stages they are indistinguishable from any other
animal species. The early zygote contains no structures that remotely correspond to any of the organs
and tissues that will make up the fully developed individual. Development consists of two distinct but
interrelated processes: growth and differentiation.
Fetal Growth

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 Growth results when cells divide and synthesize new proteins and is reflected in increased size and
weight. It is accomplished by two mechanisms: (1) hyperplasia, an increase in cell numbers, and (2)
hypertrophy, an increase in cell size. Hyperplasia is the predominant form of growth during the
embryonic period; although the rate decreases during later stages of gestation, cell division continues
in variable degrees throughout childhood. Hypertrophy is more prominent during later periods of
growth.
There is a growth pattern that is typical for each organ and tissue, but all organs progress from a
stage characterized by increase in cell number to one of growth by increase in cell size. If there is
interference with the growth pattern of an organ, the overall result is a reduction in the size and eight
of that organ. However the consequences of the inhibiting factor depend on whether the insult is
inflicted during a period of hyperplasia or a period of hypertrophy. Interruption of growth during cell
enlargement is usually only temporary and can be overcome with proper intervention. Interference
with growth during a period of cell proliferation is likely to cause irreversible growth retardation of
that organ with permanent deficit in overall cell numbers.
The overall prenatal growth pattern shows that the most rapid gain in length precedes the gain in
weight. The most rapid linear growth takes place during mid-fetal life; the most rapid gain in weight
occurs in late fetal life.
Differentiation
Differentiation is the process by which early cells are systematically modified and specialized to
form all the tissues mat are necessary to assure an organized, coordinated individual. It is
accomplished by various mechanisms (controlled mitotic division, shifts in intracellular activity, tissue
movement [migration], increase in size, increase in number, controlled cellular death, aggregation of
like cells, and inductive interaction between different tissues) in a specified, sequential order. Each step
in the differentiation process depends on successful completion of a previous step. Anything that
interferes with one of these steps, such as a mutant gene or environmental agent, will cause an arrest in
the development of that particular tissue or organ. Divergence from the normal course of development
will result in maldevelopment of a part or, if it occurs at an early age, a sequence of distortions causing
more severe or multiple malformations.
There appears to be a relationship between the incidence of one congenital anomaly and the
presence of additional anomalies in an affected child. For example, there is a striking association
between malformed ears and kidney abnormalities that reflects a common developmental stage. The
knowledge of the stage of development for a variety of organs and systems provides a valuable clue
for the examiner. When one defect is observed, closer scrutiny may reveal defects in another organ or
system related to the same stage of development.
Organogenesis
The first 8 to 12 weeks of fetal life are particularly critical to the survival of the organism. During
this time of extremely rapid development and change, the beginnings of all major organ systems are
formed, and the embryo begins to acquire the specific functions needed to integrate these organs and
organ systems into an organized, coordinated whole. This is also the period during which the organism
is most vulnerable to environmental hazards.
The overview of the major changes in the development of organs and systems outlined in Table 5-6
provides some indication of the anatomic and physiologic characteristics present in an infant born at
various stages of gestation. Although growth and development are proportionately greater in the early
weeks, the rate is somewhat uneven and variable.
ENVIRONMENTAL INFLUENCES ON PRENATAL DEVELOPMENT
During intrauterine life the developing organism is protected to a great extent by the environment
provided by the mother; however, this protection is not complete. Numerous internal and external
factors can produce injury to the embryo, especially during periods of rapid growth or differentiation.
The impact of these factors depends on the nature of the environmental change and the developmental
stage of the embryo at the time of exposure.
Sensitive Periods in Prenatal Development
Every organ, system, and body part goes through a period during which it experiences the most
rapid cell division and differentiation. During this time the organism displays a marked susceptibility

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to injurious influences. These specific stages of crucial developmental advancement are termed
sensitive, or critical periods, and the major impact of environmental factors on development always
coincides with these periods.
The developing organism is most highly susceptible, especially to structural disturbance, during the
period of organogenesis. The sensitive periods for all organs or parts do not occur simultaneously. A
part that is susceptible to adverse influences at one particular time may be resistant to the same
influence at other periods of development. At the same time another part may be highly sensitive at the
moment.
Susceptibility to environmental influences decreases as organ formation advances—the younger the
organism and the fewer the number of cells, the greater the extent of involvement when an adverse
influence is applied. During the preimplantation period, the embryo is generally considered to be
relatively resistant to environmental influences. The impact at this phase either damages all or a
majority of the dividing cells, with subsequent abortion, or it damages only a few. During the period of
intensive differentiation most teratogenic agents are highly effective and may produce a variety of
deformities. The type of defect that is produced depends on which organ is most susceptible at the time
of application. The susceptibility to teratogenic influences decreases rapidly in the later periods of
development, which are characterized by growth and elaboration of established organs. Fig. 5-14
indicates the approximate times of critical differentiation for some of the major organs and systems.
Teratogenesis
Teratogenesis (from the Greek teratos, monster, and genesis, production) refers to the origin or
method by which prenatal growth processes are disturbed to produce a structural or functional defect.
An agent capable of producing such an adverse effect is called a teratogen. In recent years the study of
defective development (teratology) has been broadened to include any birth defect—morphologic,
biochemical, or behavioral—induced at any stage of gestation that is detected at birth (fetotoxic) or
later in life (developmentally toxic).
Principles of teratology. As a result of data gathered from retrospective studies and animal
experiments, a few basic principles have emerged that present some insight into the probability of
children being affected by specific teratogens:
1. The susceptibility of the organism to teratogenic factors is determined by the stage of
development.
2. The effect of a teratogen depends on genetic predisposition. There are indications that a
teratogenic agent accentuates the incidence of those defects that occur sporadically, implying
underlying genetic instabilities.
3. A single teratogen may produce a variety of anomalies. For example, it has been established that
rubella infection of the mother can produce a variety of defects, including cataracts, deafness, heart
anomalies, and mental retardation.
4. A variety of teratogenic agents may produce similar anomalies; for example, viruses, chemicals,
and radiation can all produce a mental deficit.
5. Teratogenic anomalies may be indistinguishable from hereditary malformations (phenocopies),
for example, inherited deafness and deafness caused by maternal rubella.
6. Many teratogenic agents have little or no adverse effect on the maternal system and may even
be beneficial to the mother. For example, the drug thalidomide, an effective hypnotic drug, nontoxic to
the mother, is severely teratogenic to the fetus.
Prenatal Influences
Before birth the maternal host determines the well-being of the fetus by the manner in which she
protects, favors, or deprives it. An unfavorable maternally imposed environment may produce effects
on the fetus that are of a transient nature with few, if any, deleterious consequences or effects serious
enough to cause long-range health problems in the infant or child.
Parental age. As in genetic disorders there appears to be a relationship between maternal age and
the incidence of postnatal deficiencies, especially motor and perceptual deficits.
Chemicals. The relationship of the fetal and maternal circulations allows for the interchange of
chemical substances across the placental membrane. The limited metabolic capabilities of the fetal
liver and its immature enzyme and transport systems render the unborn child ill equipped for

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maintaining homeostasis when chemical disturbances are imposed by the mother. This includes both
substances produced by the mother in response to a disease state (such as diabetes) and exogenous
substances ingested or inhaled by the mother.
The teratogenic effect of drugs is not believed to have an effect on developing tissue until day 15 of
gestation, when tissue differentiation begins to take place. Before that time drugs usually have little
effect on the embryo, because drugs are not believed to have a significant affinity for un-differentiated
tissue. Also, until implantation takes place, at approximately 7 days after conception, the embryo is not
exposed to maternal blood that contains the drug. However some drugs may affect the uterine lining,
making it unsuitable for implantation. Drugs administered between days 15 and 90 may produce an
effect if the tissue for which it has an affinity is in the process of differentiation at that time. After 90
days, when differentiation is complete, the embyo is believed to be relatively resistant to teratogenic
effects of drugs.
It has been estimated that women take an average of four or five drugs—either prescription or over-
the-counter preparations—during their pregnancy. In addition, hormones, frequently administered as
drugs, are often classified as such. To help ensure that fewer women will inadvertently take some
chemical that might be harmful to the fetus, labels on medications are now required to include
information regarding the possible teratogenic effects of the drug. The Food and Drug Administration
has established categories that indicate known or suspected potential of a drug to produce birth defects.
To date, alcohol does not contain a warning label, although there is strong evidence that excessive
use produces some characteristic malformations in the fetus. Infants whose mothers are addicted to
narcotic analgesics are small for gestational age and are at risk for having withdrawal following
delivery.
Infectious agents. The range of pathologic conditions produced by infectious agents is large, and
the difference between the maternal and fetal effects caused by any one agent is also great. Some
maternal infections, especially during early gestation, can result in fetal loss or malformations because
the ability of the fetus to handle infections organisms is limited. The fetal immunologic system is in-
adequate, and the fetus is unable to prevent the dissemination of organisms to the various tissues.
Some infectious agents known to produce abnormalities in the fetus, such as rubella virus, toxoplasma,
cytomegalovirus, and herpes simplex virus.
Radiation. Ionizing radiation has been shown to be both mutagenic and teratogenic in humans.
Pelvic irradiation of pregnant women—from natural background radiation that is present everywhere
in varying degrees, from occupational exposure, or from diagnostic or therapeutic procedures—is
believed to be hazardous to the embryo, although the extent of teratogenicity and the exact dosage
required to induce somatic change are still under consideration. Radiation may damage the conceptus
at any time during its prenatal existence, and it is known that rapidly dividing and differentiating cells,
such as those of the embryo, have increased radiosensitivity. As with other teratogens, the type of
effect produced is closely correlated with the stage of development at which the radiation exposure
occurs.
Although data are incomplete, there are indications that a larger number of chromosome
abnormalities occur in children born to parents who have been exposed to increased preconception
radiation. The increased likelihood they have been exposed to more radiation is consistent with the
observation that chromosome abnormalities are highest in infants of older mothers, and there is an
increased frequency of occupational exposure to radiation in chromosomally abnormal fetuses. To help
prevent the possibility of radiation damage it is advisable (1) to avoid unnecessary radiation exposure,
such as elective radiographs, in women of child-bearing age except during the 2 weeks immediately
following menstruation, (2) to ask if pregnancy is a possibility, and (3) to advise both men and women
who have lower abdomen or pelvic radiographs to avoid conception for several months. Also the
harmful effects of maternal radioactive iodine (RAI) therapy on the fetal thyroid gland has led to the
conclusion that pregnancies that occur during RAI therapy should be terminated.
Mechanical factors. The intrauterine environment minimizes the possibility of trauma to the fetus;
however, during the later months of gestation, maintaining an attitude of complete flexion in the
cramped quarters of the uterus predisposes the fetus to a number of deformities, for example,
metatarsus varus, torticollis, and dislocation of the hip.

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 Defects sometimes occur as the result of amniotic bands or adhesions between the amnion and the
fetus, such as the constriction of fetal limbs by bands of amniotic tissue that inhibit the growth of distal
segments. Decrease in the production of amniotic fluid may create deformities of varying degrees as a
result of the restriction of intrauterine space, for example, malformations of the jaw and ribs,
asymmetry of the head, and compression marks on the body.
Nutritional factors. The human conceptus has no store of nutrients to sustain vital functions
during the prenatal period; therefore it must rely on the mother as its single source of nutrition. A
number of related factors, acting alone or in combination, influence fetal access to nutrients. These in-
clude reduction of maternal intake of specific nutrients and the general nutritional state of the mother.
The chronically malnourished mother has few nutritional reserves available for fetal use, and the
accumulated effects of lifetime nutritional deficiency may produce physiologic and anatomic structural
defects that impair the mother's ability to support pregnancy and contribute to difficulties during labor.
The teenage mother who has special nutritional requirements for meeting her own growth needs may
compete with the fetus for available nutrients. Diet fads, such as the Zen macrobiotic diet and some of
the new vegetarian diets, seriously compromise the health of both the mother and the fetus.
Current information indicates that the restriction of calories and protein during prenatal
development profoundly affects the size, viability, postnatal growth, and behavior of children. The
timing and duration of nutritional deprivation appear to be crucial. Of greatest concern are the conse-
quences of dietary restriction at the time the brain is undergoing the most rapid growth and
development. Insufficient nutrients to the fetus during the time of rapid brain cell division result in
permanent deficiency in brain cell numbers. The long-term consequences of nutritional deficiency may
be manifest as cognitive, behavioral, and language retardation. There is a highly complicated
relationship between maternal intake, postnatal environmental conditions, and the intellectual
functions of offspring that is worthy of further exploration.
Maternal health. Because the physiologic well-being of the fetus depends on the maternal
environment in which it grows, any disorder that affects the maternal system will have some effect on
the fetal system. Some of the specific disorders and related problems (such as diabetes mellitus and
substance abuse) are discussed in other Chapter.
Maternal smoking. It is well established that mothers who smoke during pregnancy have a higher
incidence of spontaneous abortion, complications of pregnancy, and premature delivery. The infants of
these women have lower Apgar scores, lower birth weight, lower chance of survival, and decreased
size throughout childhood. Offspring of these mothers demonstrate lower mental functioning,
increased chance of malformations, hyperkinetic behavior, and lower scholastic ability in childhood,
probably related to oxygen deprivation and exposure to the products of cigarette smoke. Nicotine and
carbon monoxide decrease the oxygen supply and blood flow to the uterus and cause vasoconstriction
in fetal organs, including the brain. It has also been shown that there is an increase in prenatal
mortality in a household where the father smokes.
Other factors. Other factors capable of affecting the fetus adversely include:
1. Physical factors such as high altitude
2. Maternal disease such as toxemia of pregnancy, metabolic disorders such as diabetes and
thyroid disease, and vascular diseases such as heart disease, lupus erythematosus, hypertension, and
the hemoglobinopathies
3. Isoimmunization from maternal-fetal blood incompatibility
4. Prenatal diagnostic and therapeutic procedures

Teratogenesis refers to the origin or method by which

prenatal growth processes are disturbed to produce a
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structural or functional defect. An agent capable of producing
such an adverse effect is called a teratogen.

Principles of teratology

1. The susceptibility of the organism to teratogenic

factors is determined by the stage of development.
2. The effect of a teratogen depends on genetic
predisposition. There are indications that a teratogenic agent
accentuates the incidence of those defects that occur
sporadically, implying underlying genetic instabilities.
3. A single teratogen may produce a variety of
anomalies. For example, it has been established that rubella
infection of the mother can produce a variety of defects,
including cataracts, deafness, heart anomalies, and mental
retardation.
4. A variety of teratogenic agents may produce similar
anomalies; for example, viruses, chemicals, and radiation
can all produce a mental deficit.
5. Teratogenic anomalies may be indistinguishable
from hereditary malformations (phenocopies), for
example, inherited deafness and deafness caused by maternal
rubella.
6. Many teratogenic agents have little or no adverse
effect on the maternal system and may even be beneficial
to the mother. For example, the drug thalidomide, an
effective hypnotic drug, nontoxic to the mother, is severely
teratogenic to the fetus.

Prenatal Influences
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 may produce effects on the fetus
that are of a transient nature with
few, if any, deleterious
consequences or effects serious
enough to cause long-range health
problems in the infant or child.

Parental age
Chemicals
Infectious agents
Radiation
Mechanical factors
Temperature
Nutritional factors
Maternal health

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Sensitive, or critical, periods in human development.
Solid color denotes highly sensitive periods;
stippled color indicates stages when embryo is less sensitive to teratogens.

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10
 Child age periods

period Intranatal
Intrauterine period (40 weeks) Childhood (up to 18 years)

TODDLER (1 to 3 years )
Embryonic Fetal period Neonatal
period period

(6 to12 years)The "school age"

(1 to 12 months)Infancy period

(13-18 years)ADOLESCENCE
(8 weeks) (birth to 28 days)

(3 to 6 years)PRESCHOOL
(7 days)Early

(8-28 days)Later
Early Later
(9-22 weeks) (22nd week till
the delivery)

Antenatal period

Perinatal period

Postnatal period
 Some infectious agents known to produce
abnormalities in the fetus, such as

TORCH-complex:
T- toxoplasma
O- other infections
R- rubella virus
C- cytomegalovirus,
H- herpes simplex virus