Physical Examination

GROWTH AND DEVELOPMENT OF AN INFANT

Infants grow rapidly both in size and in their ability to perform tasks during their first year. A
standard schedule for health care visits is for 2-week, 2-month, 4-month, 6-month, 9-month,
and 12-month visits. These visits are important for the infant because they provide time for
immunizations and health assessments; they are also important for parents because they
provide an opportunity for parents to ask questions about their child’s growth pattern and
developmental progress. They also provide opportunities for health care providers
to assess for potential problems as they first appear. Anticipatory guidance offered at these
visits can help parents prepare for the rapid changes that mark the first year of
life. When appropriate, encouraging parents to join clubs or networking groups is another way
to help to increase their knowledge base and confidence level to care for their rapidly growing
infant.

Physical Growth
The physiologic changes that occur in the infant year reflect both the increasing maturity and
growth of body organs.

Weight
As a rule, most infants double their birth weight by 4 to 6 months and triple it by 1 year. During
the first 6 months, infants typically average a weight gain of 2 lb per month.
During the second 6 months, weight gain is approximately 1 lb per month. The average 1-year-
old boy weighs 10 kg (22 lb); the average girl weighs 9.5 kg (21 lb). An infant’s weight, however,
is relevant only when plotted on a standard growth chart and compared to that child’s own
growth curve .

Height
An infant increases in height during the first year by 50%, or grows from the average birth
length of 20 in. to about 30 in. (50.8 to 76.2 cm). Height, like weight, is best assessed if it is
plotted on a standard growth chart. Infant growth is most apparent in the trunk during the
early months.
During the second half of the first year, it becomes more apparent as lengthening of the legs
occurs. At the end of the first year, the child’s legs may still appear disproportionately short,
however, and perhaps bowed. For accuracy, measure infants lying supine on a measuring board
even if they are beginning to be able to stand .
Head Circumference
By the end of the first year, the brain already reaches two thirds of its adult size. Head
circumference increases rapidly during the infant period to reflect this rapid brain growth.
Some infants’ heads appear asymmetric until the second half of the first year, especially if they
are always placed on their back to sleep (which they should be), causing the skull bones to
flatten in the back. Suggest to parents they continue to place the infant on the back to sleep but
to spend “tummy time” daily with the infant placed in a prone position to prevent this
flattening. This early head distortion will gradually correct itself as the child sleeps less and
spends more time
with the head in an erect position. Persistence of asymmetry suggests an infant is not receiving
enough stimulation or is spending the majority of time lying in bed.

Body Proportion
Body proportion changes during the fi rst year from that of a newborn to a more typical infant
appearance. By the end of the infant period, the lower jaw is defi nitely prominent and remains
that way throughout life. The circumference of the chest is generally less than that of the head
at birth by about 2 cm. It is even with the head circumference in some infants as early as 6
months and in most by 12 months. The abdomen remains protuberant until the child has been
walking well for some time, generally well into the toddler period. Cervical, thoracic, and
lumbar vertebral curves develop as infants hold up their head, sit, and walk. Lengthening of the
lower extremities during the last 6 months of infancy readies the child for walking and often is
the fi nal growth that changes the appearance from “babylike” to “toddler like.”

Body Systems
In the cardiovascular system, heart rate slows from 110 to 160 beats/min to 100 to 120
beats/min by the end of the first year. The heart continues to occupy a little over half the width
of the chest. Pulse rate may slow with inhalation (sinus arrhythmia), but this does not become
marked until preschool age. That the heart is becoming more efficient is shown by a decreasing
pulse rate and a slightly elevated blood pressure (from an average of 80/40 to 100/60 mmHg).
Infants are prone to develop a physiologic anemia at 2 to 3 months of age. This occurs because
the life of a typical red cell is 4 months, so the cells the child had at birth begin to disintegrate
at that time, yet new cells are not yet being produced in adequate replacement numbers.
Hemoglobin in an infant becomes totally converted from fetal to adult hemoglobin at 5 to 6
months of age. Infants may experience a decrease in serum iron levels at 6 to 9 months as the
last of iron stores established in utero are used. The respiratory rate of an infant slows from 30
to 60 breaths/min to 20 to 30 breaths/min by the end of the first year. Because the lumens of
the respiratory tract remain small and mucus production by the tract to clear invading
microorganisms is still inefficient, upper respiratory infections occur readily and tend to be
more severe than in adults. At birth, the gastrointestinal tract is immature in its ability to digest
food and mechanically move it along. These functions mature gradually during the infant year.
Although the ability to digest protein is present and effective at birth, the amount of amylase,
which is necessary for the digestion of complex carbohydrates, is deficient until approximately
the third month. Lipase, necessary for the digestion of saturated fat, is decreased in amount
during the entire first year. The liver of an infant remains immature, possibly causing an
inadequate conjugation of drugs (if a drug should be necessary for treatment of illness) and the
inefficient formation of carbohydrate, protein, and vitamins for storage. Until age 3 or 4
months, an extrusion reflex (food placed on an infant’s tongue is thrust forward and out of the
mouth) prevents some infants from eating effectively if they are offered solid food this early
(not recommended). Newborns can drink from a cup as long as a parent controls the fluid flow.
An infant can independently drink from a cup by age 8 or 10 months. The kidneys remain
immature and not as efficient at eliminating body wastes as in an adult. The endocrine system
remains particularly immature in response to pituitary stimulation, such as adrenocorticotropic
hormone, or insulin production from the pancreas. Without these hormones functioning
effectively, an infant may not be able to respond to stress as effectively as an adult.

Teeth
The first baby tooth (typically a central incisor) usually erupts at age 6 months, followed by a
new one monthly. However, teething patterns can vary greatly among children. Figure 29.1
illustrates the usual ages of deciduous (baby teeth) eruption by tooth type. Some newborns
(about 1 in 2,000) may be born with teeth (natal teeth) or have teeth erupt in the first 4 weeks
of life (neonatal teeth). The lower central incisors are the teeth most frequently involved in this
early growth. These very early teeth may be membranous and so may be reabsorbed
(supernumerary or extra teeth). If they are loosely attached, they are usually removed before
they loosen spontaneously and are aspirated by the infant. In most infants, however, natal or
neonatal teeth are deciduous or are fixed firmly. These should not be removed because no
other teeth will grow to replace them until the permanent teeth erupt at age 6 or 7. Deciduous
teeth are essential for allowing proper growth of the dental arch. If they are injured, children
need conscientious follow-up to be certain there is space for permanent teeth to erupt
effectively or that permanent teeth are not discolored.

Motor Development
An average infant progresses through systematic motor growth during the first year, strongly
reflecting the principles of cephalocaudal (head to toe) and gross to fi ne motor development.
Control proceeds from head to trunk to lower extremities in a progressive, predictable
sequence. As different infants show individual variations in accomplishing different tasks, the
ages given here are only averages. To assess motor development, both gross motor
development(ability to accomplish large body movements) and fi ne motor development ,
measured by observing or testing prehensile ability(ability to coordinate hand movements), are
evaluated.

Gross Motor Development

Four positions—ventral suspension, prone, sitting, and standing—are used to assess gross
motor development. Ventral Suspension Position. Ventral suspension refers to an infant’s
appearance when held in midair on a horizontal plane and supported by a hand under the
abdomen In this position, the newborn allows the head to hang down with little effort at
control. One-month-old infants lift their head momentarily, then drop it again. Two-month-old
infants hold their head in the same plane as the rest of their body, a major advance in muscle
control. By 3 months, infants lift and maintain their head well above the plane of the rest of the
body in ventral suspension. A Landau reflex is a new reflex that develops at 3 months. When
held in ventral suspension, the infant’s head, legs, and spine extend. When the head is
depressed, the hips, knees, and elbows flex. This reflex continues to be present in most infants
during the second 6 months of life, but then it becomes increasingly difficult to demonstrate. It
is an important reflex to assess because a child with motor weakness, cerebral palsy, or other
neuromuscular defects will not be able to demonstrate the reflex. At 6 to 9 months, an infant
also demonstrates a parachute reaction from a ventral suspension position. This means that
when infants are suddenly lowered toward an examining table, the arms extend as if to protect
themselves from falling. Children with cerebral palsy do not demonstrate this response because
they fl ex their extremities too tightly. Prone Position. When lying on their stomach, newborns
can turn their head to move it out of a position where breathing is impaired, but they cannot
hold their head raised for an extended time By 1 month of age, they lift their head and turn it
easily to the side. They still tend to keep their knees tucked under their abdomen, however, as
they did as a newborn. Two-month-old infants can raise their head and maintain the position,
but they cannot raise their chest high enough to look around yet. Their head is still held facing
downward. A 3-month-old child lifts the head and shoulders well off the table and looks around
when prone. The pelvis is flat on the table, no longer elevated. Some children can turn from a
prone to a side-lying position at this age.