 Growth and development proceed in an
PRINCIPLES GROWTH AND DEVELOPMENT
To assess growth (defined as an increase in
physical size, typically measured as height, weight
and head circumference), measure and plot height
and weight on a standard growth chart for children
at all well-child care visits.
 Development refers to the progression toward
maturity in mental, physical, and social markers of
normal development
An Oedipus complex refers to the strong
emotional attachment a preschool boy
demonstrates toward his mother; an Electra
complex is the attachment of a preschool girl to
her father.
NURSING DIAGNOSIS  
 Risk for delayed growth and development
related to lack of age-appropriate toys and
activities  by practice
 Delayed growth and development related to
prolonged illness Readiness for enhanced
family coping related to parents seeking
information about a child’s growth and
development
  Health-seeking behaviors related to
appropriate stimulation for infants
  Imbalanced nutrition, less than body
requirements, related to parental knowledge
deficit regarding a child’s protein needs   Genetics may affect the child’s G&D by
 Deficient knowledge related to potential
long-term effects of obesity in the school-
age child
ROLE OF THE NURSE IN G&D
Assessing growth and development milestones is a
nursing role in the care of both well and ill children.
PRINCIPLES OF G&D
 Growth is used to denote an increase in
physical size or a quantitative change.  therapy or care available for the disease
 Development indicates an increase in skill
or the ability to function (a qualitative
change)
  Maturation is a synonym for development.
 Psychosexual development is a specific
type of development that refers to
developing instincts or sensual pleasure
(Freudian theory)
 Psychosocial development refers to
Erikson’s stages of personality development
 Kohlberg’s theory of moral development is
the ability to know right from wrong and to
apply these to real-life situations
 Cognitive development refers to the ability
to learn or understand from experience, to
acquire and retain knowledge, to respond to
a new situation, and to solve problems
(Piaget’s Theory)
 Neurologic tissue (spinal cord and brain) grows
so rapidly during the first 2 years that the brain
reaches mature proportions by 2 to 5 years of age.
Lymphoid tissue (spleen, thymus, lymph nodes,
and tonsillar tissue) also grows rapidly during
infancy and childhood to provide young children
early protection against infection
GENERAL PRINCIPLES OF G&D
 Growth and development are continuous
processes from conception until death. 
orderly sequence.
 Children pass through the predictable
stages at different rates.
 All body systems do not develop at the
same rate
 Development is cephalocaudal (Cephalo is
a Greek word meaning “head”; caudal
means “tail.” Development proceeds from
head to tail )
 Development proceeds from proximal to
distal body parts.( It can best be illustrated
by tracing the progress of upper extremity
development.)
 Development proceeds from gross to
refined skills
 There is an optimum time for initiation of
experiences or learning
Neonatal reflexes must be lost before
development can proceed
 A great deal of skill and behavior is learned
FACTORS INFLUENCING G&D
 Temperament- the usual reaction pattern of
an individual or an individual’s characteristic
manner of thinking, behaving, or reacting to
stimuli in the environment. Unlike cognitive
or moral development, temperament is not
developed in stages but is an inborn
characteristic set at birth.
inheriting the genetic abnormalities that may
result in disability or illness at birth or later in
life and may prevent optimal growth.
 Gender- On average, girls are born lighter
(by an ounce or two) and shorter (by an inch
or two) than boys.
 Health- A child who inherits a genetically
transmitted disease may not grow as rapidly
or develop as fully as a healthy child
depending on the type of illness and the
 Intelligence- Children with high intelligence
do not generally grow faster physically than
other children, but they do tend to advance
faster in skills
 Environment- For example, a child could
receive inadequate nutrition because of a
family’s low socioeconomic status, a parent
could lack childcare skills or not give a child
enough attention or stimulation, or a child
could contract an infectious disease and be
left with a long-term disability.
ENVIRONMENTAL INFLUENCES:
 Socioeconomic level
 The Parent-child relationship
 Ordinal Position in the Family
 Health
 Nutrition
CATEGORIES OF TEMPERAMENT
 The Easy Child - Children are rated as
“easy to care for” if they have a predictable
rhythmicity, approach and adapt to new
situations readily, have a mild-to-moderate
intensity of reaction, and have an overall
positive mood quality.
 The Intermediate Child- Some
characteristics of both easy and difficult
groups are present
  The Difficult Child- Children are “difficult” if
they are irregular in habits, have a negative
mood quality, and withdraw rather than
approach new situations
 The Slow-to-Warm-Up Child- Children fall
into this category if, overall, they are fairly
inactive, respond only mildly and adapt
slowly to new situations, and have a general
negative mood. About 15% of children
display this pattern
THEORIES OF CHILD DEVELOPMENT
Developmental tasks are a skill or a growth
responsibility arising at a particular time in an
individual’s life, the achievement of which will
provide a foundation for the accomplishment of
future tasks.
BASIC DIVISIONS OF CHILDHOOD
Neonate- First 28 days of life
 Infant -1 month–1 year  Preconventional Lv. 1
Toddler- 1–3 years  2-3 Punishment-obedience Orientation (right &
Preschooler- 3–5 years  wrong is based on physical consequences given by
School-age child- 6–12 years
 Adolescent- 13–17 years
 Late adolescent- 18–21 years
FREUD’S PSYCHOANALYTIC THEORY
The theory, based on Freud’s observations of
mentally disturbed adults, described adult behavior
as being the result of instinctual drives of a
primarily sexual nature (libido).
Infant- oral stage
Toddler- anal stage
Pre-schooler- phallic stage
School age- latent stage
Adolescent- Genital stage
ERIKSON’S PSYCOSOCIAL DEVELOPMENT
THEORY
a theory that stresses the importance of culture and
society in development of the personality
Whereas Freud looked at ways mental illnesses
develop, Erikson looked
at actions that lead to mental health.
Infant- Trust vs Mistrust
Toddler- Autonomy vs shame or doubt
Preschooler- Initiative vs guilt
School Age- Industry vs inferiority
Adolescent- Identity vs role confusion
Late Adolescent- Intimacy vs isolation
PIAGET’S COGNITIVE DEVELOPMENT THEORY
Piaget defined four stages of cognitive
development, within the stages of growth, then
finer units or schemas. To progress from one
period to the next, children reorganize their thinking
processes to bring them closer to adult thinking
Infant- Sensorimotor stage
Toddler- Preoperative period (symbolic thought and
egocentric thinking)
Preschooler- intuitive thinking (strongly influence by
role fantasy and use of assimilation)
School age- operational thought (use of practical
solutions and begins to recognize cause and effect
relationships)
Adolescent- formal operational (can use abstract
thought than concrete thought/ can go more
specific than general)
KOHLBERG’S MORAL DEVELOPMENT THEORY
developed a theory on the way children gain
knowledge of right and wrong or moral
reasoning
the parents)
4-7 Individualism (satisfying own needs rather than
the needs of the majority/ give and take stage)
Conventional Lv. 2
7-10 Good boy/girl orientation (the need to do good
things to be good in own eyes and eyes of others)
10-12 Social order (following the rules feels
satisfying)
Post conventional Lv. 3
Older than 12 Social contract and personal
principle orientation (Follows rules for the good of
the majority)
Older than 12 Universal principle orientation
( follows the standards of conduct)
KEY POINTS FOR REVIEW
 Knowledge of growth and development
is important in health promotion and illness
prevention because it lays the basis for
assessments and anticipatory guidance.
 Including growth and development
guidelines in nursing care helps to achieve
care that not only meets QSEN
competencies but also best meets a family’s
total needs.
 Genetic factors that influence growth and
development are gender, ethnicity,
intelligence, and health.
 Environmental influences include quality
of nutrition, socioeconomic level, the
parent–child relationship, ordinal position in
the family, and environmental health.
 To meet growth and development
milestones, children (like adults) need to
follow basic guidelines for a healthy diet,
such as eating a variety of foods,
maintaining an ideal weight, avoiding
extreme levels of saturated fat, eating foods
 with adequate starch and fiber, and avoiding
too much sugar.
 Temperament is a child’s characteristic
manner of thinking, behaving, or reacting.
Helping parents understand the effect of
temperament is a nursing role.
 Common theories of development are
Freud’s psychoanalytic theory and
Erikson’s theory of psychosocial
development. Both of these theories
describe specific tasks children must
complete at each stage of development to
become a well-adapted adult.
 Piaget’s theory of cognitive development
describes ways children learn.
 Kohlberg advanced a theory of moral
development or how children use moral
reasoning to solve problems.
 Although growth and development occur in
known patterns, the rate that a child
develops and grows varies from child to
child.
 Caution parents not to be concerned that
two siblings are very different as long as
they both fit within usual parameters.
NURSING CARE OF A FAMILY WITH AN INFANT
The Nursing Role in Health Promotion of an
Infant and Family
The nursing role with infants is wide ranging
because infants are so dependent on their
caregivers for safety, learning, and emotional
development
ASSESSMENT
Nursing assessment of an infant begins with an
interview with the primary caregiver. Important
areas to discuss include nutrition, elimination,
growth patterns, and development. An infant’s
height, weight, and head circumference are
important indicators of growth, so they should be
measured and plotted on standard growth charts
NURSING DIAGNOSIS
 Ineffective breastfeeding related to maternal
fatigue
 Disturbed sleep pattern (maternal) related to
baby’s need to nurse every 2 hours
 Deficient knowledge related to normal infant
growth and development
 Imbalanced nutrition, less than body
requirements, related to infant’s difficulty
sucking
 Health-seeking behaviors related to
adjusting to parenthood
 Delayed growth and development related to
lack of stimulating environment
 Risk for impaired parenting related to long
hospitalization of infant
 Readiness for enhanced family coping
related to increased financial support
 Social isolation (maternal) related to lack of
adequate social support
 Ineffective role performance related to new
responsibilities within the family
GROWTH AND DEVELOPMENT OF AN INFANT
PHYSICAL GROWTH- The physiologic changes
that occur in the infant year reflect both the
increasing maturity and growth of body organs.
WEIGHT
 most infants double their birth weight by 4 to
6 months and triple it by 1 year
 1ST 6 months, average gain weight of 2lb
per month
 2nd 6 months, weight gai of approximately
1lb per month
 Average 1 year-old Boy weighs 10 kg
(22lb); Average 1 year old girl weighs 9.5
kg (21lb)
HEIGHT
Infants height increases during 1st year by 50% or
grows from the average birth length of 20 in. to
about 30 in. (50.8 to 76.2 cm). During the second
half of the first year, it becomes more apparent as
lengthening of the legs occurs.
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. Infants’
heads appear asymmetric until the second half
of the first year
BODY PROPORTIONS
 The circumference of the chest is generally
less than that of the head at birth by
about 2 cm. 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 final
growth that changes the appearance from
“babylike” to “toddler like.”
BODY SYSTEMS
 cardiovascular system, heart rate slows
from 110 to 160 beats/min to 100 to 120
beats/min by the end of the first year.
 Pulse rate may slow with inhalation
(sinus arrhythmia), but this does not
become marked until preschool age
 Infants are prone to develop a physiologic
anemia at 2 to 3 months of age.
 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.
 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).
 An infant can independently drink from a
cup by age 8 or 10 months.
  An infant’s immune system becomes
functional by at least 2 months of age; an
infant can actively produce both immune
globulin (Ig)G and IgM antibodies by 1 year.
The levels of other immunoglobulins (IgA,
IgE, and IgD) are not plentiful until
preschool age, which is the reason why
infants continue to need protection from
infection
 The ability to adjust to cold is mature by
age 6 months
TEETH
 The first baby tooth (typically a central
incisor) usually erupts at age 6 months,
followed by a new one monthly
 Fluoride supplementation should be
administered at 6 months of age
 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)
 In most infants, 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
years.
 Deciduous teeth are essential for allowing
proper growth of the dental arch.
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-fine motor development.
 Control proceeds from head to trunk to
lower extremities in a progressive,
predictable sequence.
 To assess motor development, both gross
motor development (ability to accomplish
large body movements) and fine motor
development, measured by observing or
testing prehensile ability (ability to
coordinate hand movements), are
evaluated.
 GROSS DEVELOPMENT- Four positions—
ventral suspension, prone, sitting, and
standing—are used to assess gross motor
development
Ventral suspension refers to an
infant’s appearance when held in
midair on a horizontal plane and
supported by a hand under the
abdomen. 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
(present during 2nd 6 months of life in
infants). 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.
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. The first time,
this tends to occur as an extension
of lifting the chest combined with a
neck-righting reflex
Sitting Position When placed on
his or her back and then pulled to a
sitting position, a newborn has
extreme head lag; this lag is present
until about 1 month. This is a major
milestone in development that
should always be considered in an
assessment. Children with delayed
cognitive or motor development
may not accomplish this step at
this time. A 7-month-old child can
sit alone but only when the hands
are held forward for balance. An 8-
month-old child can sit securely
without any additional support
Standing Position A newborn
stepping reflex can still be
demonstrated at 1 month of age. A
child has until about 22 months of
age to walk and still be within the
normal limit, however an 11-month-
old child cruising along the walls.
Further childproofing of the house
will be necessary to keep the child
safe.
FINE MOTOR DEVELOPMENT
 Thumb opposition (ability to bring the
thumb and fingers together) begins, but the
motion is a scooping or raking one, not a
picking-up one, and is not very accurate
 A major milestone at 10 months is the ability
to bring the thumb and first finger together
in a pincer grasp
SUMMARY OF INFANT GROWTH AND
DEVELOPMENTAL MILESTONES
 0-1 month largely reflex actions
 2 month holds head when prone
 3 month holds head and chest up when
prone
 4 month turns back to front; no longer has
head lag; bears partial weight on feet
 5 month should turn readily front to back
and back to front
 6 month beginning to show ability to sit
 7 month reaches out to be picked up; first
tooth (central incisor) erupts
 8 month sits securely without support
 9 month creeps or crawls (abdomen off
floor)
 10 month pulls self to standing
 11 month cruises (walks with support)
 12 month stands alone; some infants take
first step
LANGUAGE DEVELOPMENT
Language develops step by step the same as
motor development. Infants begin to make small
cooing (dovelike) sounds by the end of the first
month.
  By 12 months, infants can generally say
two words in addition to “ma-ma” and
“da-da,” and they use those two words with
meaning.
DEVELOPMENT OF SENSES
VISION
One-month-old infants are able to regard an
object in the midline of their vision (something
directly in front of themselves) as soon as it is
brought in as close as about 18 in. (46 cm)
 The ability to follow and focus in this way is
a major milestone in development,
indicating that an infant has achieved
binocular vision, or the ability to fuse two
images into one
 Three-month-old infants can follow an
object across their midline. They typically
hold their hands in front of their face and
study their fingers for long periods of time
(hand regard)
 By 10 months, an infant looks under a towel
or around a corner for a concealed object
(the beginning of object permanence, or an
awareness that an object out of sight still
exists).
HEARING
That an infant can hear can be demonstrated at
birth by the way a newborn quiets momentarily at a
distinctive sound such as a bell or a squeaky
rubber toy
 By 10 months, infants can recognize their
name and listen acutely when spoken to
 By 12 months, infants can easily locate
sounds in any direction and turn toward
them. A vocabulary of two words plus “ma-
ma” and “da-da” also demonstrates that an
infant can hear.
TOUCH
Infants need to be touched so they can experience
skin-to-skin contact. Clothes should feel
comfortable and soft rather than rough; diapers
should be dry rather than wet. Teach parents to
handle infants with assurance yet gentleness.
TASTE
Infants demonstrate they have an acute sense of
taste by turning away from or spitting out a
taste they do not enjoy. When infants are
introduced to solid food at about 6 months, urge
parents to make mealtime a time for fostering trust
as well as supplying nutrition by being certain
feedings are done at an infant’s pace and the
amount offered fits the child’s needs and not the
parent’s idea of how much should be eaten.
SMELL
Infants can smell accurately within 1 or 2 hours
after birth. They respond to an irritating smell by
turning their head away from it.
EMOTIONAL DEVELOPMENT
Socialization, or learning how to interact with
others, is an extensive phenomenon. Onemonth-
old infants show they can differentiate between
faces and other objects by studying a face or the
picture of a face longer than other objects. They are
calm and feed well for the person who has been
their primary caregiver.
 When an interested person nods and smiles
at a 6-week-old infant, the infant smiles in
return. This is a social smile and is a definite
response to the interaction, not the faint,
quick smile that younger infants, even
newborns, demonstrate
 Fear of strangers reaches its height during
the eighth month, so much so that this
phenomenon is often termed eighth-month
anxiety, or stranger anxiety
 By 12 months, most children have
overcome their fear of strangers and are
alert and responsive again when
approached. They like to play interactive
nursery rhymes and rhythm games and
“dance” with others.
COGNITIVE DEVELOPMENT
In the first month of life, an infant mainly uses
simple reflex activity. They demonstrate they are
very people oriented moments after birth by
cuddling against an adult’s chest.
PRIMARY AND SECONDARY CIRCULAR
REACTION
 By the third month of life, a child enters a
cognitive stage identified by Piaget (1952)
as primary circular reaction. Infants
appear to be unaware of what actions they
can cause or what actions occur
independently.
 At about 6 months of age, infants pass
into a stage Piaget (1952) called
secondary circular reaction. Now when
infants reach for a mobile above the crib, hit
it, and watch it move, they realize it was
their hand that initiated the motion, and so
they hit it again.
 By 10 months, infants discover object
permanence. Infants are ready for peek-a-
boo once they have gained this concept.
They know their parent still exists even
when hiding behind a hand or blanket and
wait excitedly for the parent to reappear.
KEY POINTS FOR REVIEW
 The infant period is from 1 month to 12
months of age. Children typically double
their birth weight at 4 to 6 months and triple
it at 1 year.
 Infants develop their first tooth at about 6
months; by 12 months, they have six to
eight teeth. Important gross motor
milestones during the infant year are lifting
the chest off a bed at 2 months, sitting at 6
to 8 months, creeping at 9 months, cruising
at 10 to 11 months, and walking at 12
months.
 Important fine motor accomplishments are
the ability to pass an object from one hand
to the other (7 months of age) and a pincer
grasp (10 months of age).
 Important milestones of language
development during the first year are
differentiating a cry (2 months of age),
making simple vowel sounds (5 to 6 months
of age), and saying two words besides “ma-
ma” and “da-da” (12 months of age).
  The more infants are spoken to, the easier it
is for them to acquire language.
 Providing infants with proper toys for play
helps development.
 All infant toys need to be checked to be
certain they are too large to be aspirated
(wider than a toilet paper roll).
 Important milestones of vision development
are the ability to follow a moving object past
the midline (3 months of age) and ability to
focus securely without eyes crossing (6
months of age).
 According to Erikson (1993), the
developmental task of the infant year is the
development of a sense of trust versus
mistrust.
 Helping parents spend quality time with their
infant helps a sense of trust to develop and
helps in planning nursing care that not only
meets QSEN competencies but that also
best meets the family’s total needs.
 Safety is important.
 Infants must be protected from falls and the
aspiration of small objects.
 Skills an infant cannot accomplish one day,
such as crawling (which can lead to
danger), may be accomplished the next.
 Solid food is generally introduced into an
infant’s diet at 6 months of age. Before
infants can eat solid food, they must lose
their extrusion reflex.
 Common concerns related to infant
development include teething, thumb-
sucking, use of pacifiers, sleep problems,
constipation, colic, diaper dermatitis, baby-
bottle syndrome (decayed teeth from
sucking on a bottle of formula while they
sleep), and obesity.
 Nurses play a key role in teaching parents
about these problems and suggestions to
deal with them.
 Remember that parent–infant attachment is
critical to mental health.
 Urge parents to continue to give as much
care as possible to ill infants to maintain this
important relationship.
PEDIATRIC ASSESSMENT CONSIDERATIONS
NEWBORNS
 PE is performed after birth and 24 hours
after birth
 Prioritize thermoregulation
 Axillary and tympanic temperature is
preferred over rectal temperature (vs. rectal
mucosa injury)
 Apical pulse is taken to avoid discrepancies
due to immature peripheral circulation
INFANTS
 Let the parent hold the infant during the PE
to calm the child.
 Start with the least invasive procedure first
(assessing respiration).
 Reflexes are assessed routinely until 6
months unless the child has cardiac
anomalies.
 Head circumference is assessed routinely
until the child reaches 1 year.
 Similar assessment parameters to newborn
assessment
TODDLERS
 Allow the child to play with the tools to
be used prior to PE.
 Gain the parent’s trust first, because this
will be the basis of the child’s trust on
you.
 Generously praise the child for
cooperating the in assessment.
 Enforce the child’s independence during
assessment (e.g. let him remove his
clothes on his own).
 Assure the child that the procedure will
not hurt him.
 BP is taken routinely by 3 years old.
 Oral temperature may be taken.
SCHOOL-AGE & ADOLESCENT
 Always explain the procedure to the
child.
 Offer the child the choice to whether
being with the parent during the
examination.
 Provide privacy.
 Instruct that testicular self-examination
may be performed routinely by age of 13
years old.
 Instruct that breast self-examination
must be performed routinely by age of
20 years old.
SIGNIFICANT DIFFERENCES AND
CONSIDERATIONS FROM ADULT
ASSESSMENT
 Vital signs
 General appearance
 Mental status
 Body measurements
o Height and Weight
-Infants: Weigh infants while
he lies down or sits on scale.
Weigh him nude.
o - Children > 2 y.o.: Have the child
positioned on a standing scale.
Weigh him each day
wearing similar clothing, at the same
time, using the same scale.
o - Standard graphs are used in
determining appropriate weight-for-
height measures. The child’s
weight for height is normal if it fails
between the 10th – 90th percentile
of the graph. If weight for height
falls <3rd percentile, the child
exhibits failure to thrive.
B. Head circumference
- place the tape measure round the infant’s
eyebrows and around the occipital prominence
(most prominent part on the back of the head).
- Normal findings: 33 – 35 cm
C. Chest and abdominal
circumference
 - Chest circumference – place the tape
measure at the level of the nipples then around
the child’s chest.
- Abdominal circumference – place the
tape measure at the level of the umbilicus then
around the child’s abdomen.
- Normal findings (for both): 31- 33 cm
PHYSICAL ASSESSMENT
HEAD
CAPUT SUCCEDANEUM- swelling (edema) that
affects a newborn's scalp. It most commonly occurs
from pressure on the head as the baby moves
through the birth canal during a prolonged or
difficult vaginal delivery.
SUBGALEAL HEMORRHAGE- A subgaleal
hemorrhage is an accumulation of blood that forms
between your newborn's skull and the skin on their
scalp. The condition can occur after a difficult
vaginal delivery, especially if your healthcare
provider needs to use a vacuum extractor.
CEPHALOHEMATOMA- a minor condition that
occurs during the birth process. Pressure on the
fetal head ruptures small blood vessels when the
head is compressed against the maternal pelvis
during labor or pressure from forceps or a vacuum
extractor used to assist the birth
EYES
 Subconjunctival hemorrhage is normal in
newborns.
 Assess the red reflex for congenital
cataract.
NOSE
 Remember: Newborns and infants are
obligate nose breathers.
EARS
 Low set ears suggest presence of
chromosomal aberration.
 3 years old and younger: pull the pinna
down and back.
 3 years and older: pull the pinna up then
back.
MOUTH
 Do not assess the child’s epiglottis if he is
suspected with epiglottitis. – Increase risk of
airway obstruction
 Assess newborns for oral thrush (white
patches in the tongue or buccal mucosa).
HEART
PMI (Point of Maximal Impulse) for children
younger than 4 years old: 4th ICS, Left AAL/lateral
to the nipple.
PMI for children older than 4 years old (4-7
years old):
5th ICS Left MCL
Sinus arrythmia (marked increase in HR upon
inhalation, then marked decreased in HR upon
exhalation) is normal in most school-age children
and adolescents. To assess HR properly, ask the
child to hold his breath while taking the HR.
Physiological splitting of S2 is normal as long as it
coincides with inspiration.
ABDOMEN
 Use diaphragm to properly assess for high-
pitched bowel sound, which can be heard
one hour following birth.
 If the child is ticklish in the abdomen,
distract him during assessment.
GENITORECTAL AREA
Assess for the following structural alterations that
may affect fertility in adulthood:
Hypospadias: urethral opening is at the
inferior/ventral/lower surface
Epispadia: urethral opening is at the
superior/dorsal/upper surface
Hydrocele: fluid-filled scrotal sac; glows with
transillumination
Varicocele: enlarged vein of the epididymis
INGUINAL HERNIA
 In infants, seen as a bulge in the groin area
especially when crying.
 In school-age children and adolescents,
this is assessed with the child standing up
and by placing a fingertip at the inguinal ring
in the groin area, then coughing.
VISION
 Routinely assessed by 3 years of age
 Newborns are able to follow objects until
midline only at a distance approximately 8-
10 inches.
 Infants and toddlers are able to follow
objects past midline.
 Eye charts used in assessing vision include:
Snellen’s chart, Preschool E chart (if unable
to read or using different language), Allen
cards (similar pictures instead of words on
flashcards asked to be identified at a
distance of 15 feet), and Ishihara plates (for
color vision; normally, the child will identify
images in the plates
HEARING
Routinely assessed by 3 years of age
Speech
DEVELOPMENTAL MILESTONES
Use of Metro Manila Developmental Screening Test
with the following parameters: personal-social, fine
motor-adaptive, language, and gross motor.
COGNITIVE DEVELOPMENT
Temperament: inborn reaction pattern of
individuals/manner of thinking, behaving, reacting.
Easy child: predictable, with mild to moderate
intensity of reactions; presents with positive moods
Difficult child: child with irregular habits and
negative mood; appears withdrawn
Slow-to-Warm-Up child: overall fairly inactive,
slowly adapts to situation; generally negative mood
Immunization

CARE FOR THE NEWBORN
Neonate
First 28 days/4 weeks of life following
birth.
Major physiological adjustments to
extrauterine life.
The major psychological task of
neonates is to adjust to the parental
figures.
Bonding is the formation of attachment
between parent and child.
Nursing implications
Complete and thorough physical
assessment includes evaluation of
neonate’s reflexes, respiratory and
cardiac functioning.
The Apgar assessment tool is
performed at 1 minute and again at
5 minutes.
Parents are encouraged to cuddle the
newborn and establish eye contact.
Bonding between a parent and neonate;
consider the factors that may have an
impact on the early attachment between this
father and daughter.
Wellness Promotion during the Neonate Period
 Teaching basic newborn needs (to be held,
rocked, and talked to).
 Teaching hygienic practices.
 Monitoring nutritional status.
 Conducting screening tests.
 Promoting early parent-neonate interaction.
Safety Considerations during the Neonate Period
Accidents are the primary cause of neonatal
mortality.
Teaching parents about infant seats
Maintenance of skin integrity
Physical development
Considerations and Significant Findings
1. Body Measurements
Weight
2.5 – 3.4 kg
Weight loss 5% -10% by 3-4 days after birth
Weight gain by 10th days of life
Gain ¾ kg by the end of the 1st month
1. Body Measurements
They loose 5 % to 10 % of weight by 3-4 days
after birth as result of :
Withdrawal of hormones from mother.
Loss of excessive extracellular fluid (ECF).
Passage of meconium (feces) and urine.
Limited food intake.
1. Body Measurements
Height
Boys average Height = 50 cm
Girls average Height = 49 cm
Normal range for both (47.5- 53.75 cm)
Head circumference
33-35 cm
Head is ¼ total body length
Skull has 2 fontanels (anterior & posterior)
1. Body Measurements
Anterior Fontanel
Diamond shapeThe junction of the sagittal, corneal
and frontal sutures forms it
Between 2 frontal & 2 parietal bones
3-4 cm in length and 2-3 cm width
It closes at 12-18 months of age
1. Body Measurements
Posterior Fontanel
Triangular shape
Located between occipital and 2 parietal bones
Closes by the end of the 1st month of age/ 2-3
months
Chest circumference
31-33 cm
(usually 2–3cm less than head circumference).
2. Vital Signs
Temperature
36.3 to37.2C
The newborn has difficulty regulating body
temperature due to low body fat content
Brown fat is present in newborns. Breakdown of
these aids in thermoregulation by increasing
metabolism.
Skin-to-skin contact is highly encouraged
Newborns are unable to shiver, contributing to
thermoregulatory impairment
Provide early newborn care quickly to avoid heat
loss
MECHANISMS OF HEAT LOSS:
Convection: flow of heat from newborn to cooler
surrounding air.
Conduction: body heat transfer through direct
contact with cooler solid object.
Radiation: body heat transfer though indirect
contact with cooler solid object.
Evaporation: heat loss by vapor/liquid.
PULSE
120 to 160 bpm
Rate: slightly irregular – due to immaturity of
cardiac regulatory centers
Transient murmurs may be present due to
incomplete closure of fetal circulation shunts.
PERIPHERAL PULSES
Normally, femoral and brachial pulses are palpable.
Brachial pulse is sued in PALS/BLS in neonates.
If (+) femoral pulse, suspect coarctation of aorta.
Normally, radial and temporal pulses are non-
palpable.
If (+) radial pulse, suspect patent ductus arteriosus
(PDA).
RESPIRATION
Normal: 30 – 60 bpm
Physiologic apnea (<15 seconds is normal)
When counting breaths, observe neonate’s
abdomen
BLOOD PRESSURE
Not assessed routinely unless child is suspected to
have cardiac anomalies.
3. CARDIOVASCULAR SYSTEM
Acrocyanosis (pallor of the extremities with
pinkish trunk) is normal. Cause: Immaturity of
peripheral circulation
Pressure changes in the cardiopulmonary system
following a neonate’s first breath cause closing of
the fetal circulation shunts.
Elevated RBC & WBC (due to trauma associated
with childbirth) and decreased clotting factors (due
to inability of a neonate’s body to synthesize
Vitamin K initially) are expected.
4. RESPIRATORY SYSTEM
Vaginal birth is effective in expelling liquid in the
lungs.
5. GASTROINTESTINAL SYSTEM
Initially the GIT is sterile. Bacterial flora that
develops 24 hours after birth is necessary in
synthesizing Vitamin K to preventing bleeding.
Neonates are prone to regurgitation because of the
immaturity of cardiac sphincter.
Lower protein and glucose levels due to liver
immaturity, which is responsible for the synthesis of
protein and storage of glucose.
6. STOOL
MECONIUM
1st stool
Sticky, tart-like, blackish green, odorless
Composed of mucus, vernix, hormones, and
carbohydrates formed during the intrauterine
period.
Passed within 24-48 hours of birth
TRANSITIONAL PHASE
Passed during 2nd – 3rd day of life
Green and loose
BREASTFEED STOOLS
Passed during by the 4th day of life
Passed 3-4 times daily
Light yellow and sweet smelling
FORMULA-FED STOOLS
Passed during 2-3 times daily
Bright yellow and with slightly more noticeable odor
compared to breastfeed stools
Bile duct obstruction is characterized by
acholic/clay-colored/gray stool
Red-streaked stools suggest presence of anal
fissure
Mucoid/watery, loose stools may be caused by milk
allergy, lactose intolerance, indigestion, or
malabsorption
 URINARY SYSTEM
Voiding occurs within 1st 24 hours of life
Forceful urination suggests possible obstruction
 IMMUNE SYSTEM
Fully functional by 2 months of age
 NEUROMUSCULAR SYSTEM
Twitching/flailing movements of extremities in
absence of stimulus occurs because of immaturity
of nervous system
Blink reflex: present to protect the eye form any
object by rapid eye closure; triggered by shining a
strong light to the eye or by sudden movement
towards the eye.
Rooting reflex: brushing or stroking the corner of a
baby’s mouth causes him to turn his head towards
the side brushed or stroked; present for the child to
identify presence of food.
Disappears by 6 weeks of age, when the child is
able to focus
Sucking reflex: suction motions are made by the
child when his lips are touched; helps in finding
food
Disappears by 6 months of age
Swallowing reflex: occurs when the food reaches
the posterior third of the tongue.
Extrusion reflex: the tongue extrudes whenever
something is placed on its anterior portion; helps
prevent ingestion of inedible objects
Disappears by 4 month of age
Palmar grasp reflex: a newborn grasps objects
placed at the palm of his hand
Disappears by 6 weeks to 3 months of age
Step/Walk-in-Place reflex: hold the child in
standing position against a hard surface causes
him to make quick, alternating steps
Disappears by 3 months
Placing reflex: toughing the anterior surface of the
lower leg of the child against a hard surface causes
lower leg of the child against a hard surface causes
him to make quick, alternating steps
Plantar grasp reflex: grasping motion happens
when an object touches the soles of the child’s feet
at the base of the toes.
Disappears by 8-9 months of age
Tonic neck/Boxer/Fencing reflex: with the
newborn lying on his back, the head of the child
rolls into one side; his extremities on the side where
his head rolled are extended, while the extremities
on the opposite side are flexed
Disappears by 2-3 months
Moro/startle reflex: startling the newborn causes
the infant to abduct and extend their arms and legs
with their fingers in C-position, then they will adduct
their arms and legs; as a form of protection.
Disappears by 4-5 months of age
Babinski reflex: stroking the foot in an inverted J
curve from the heal upward causes fanning of the
toes.
Disappears by 3 months
Magnet reflex: applying pressure on the soles of
the child lying in supine position triggers him to
push back against the pressure
Crossed extrusion reflex: with an extended leg of
an infant in supine position and its corresponding
foot irritated by a sharp object, the opposite leg is
raised and extended, as if pushing the object away
form the other foot.
Trunk incurvation reflex: touching the
paravertebral area of a child in prone position
causes flexion of the child’s trunk and swinging of
the child’s hip towards the touch
Landau reflex: muscle tone must be manifested by
placing the child in a prone position with a hand
underneath, supporting the trunk.
Parachute reflex: lowering the child back to the
examination table in ventral suspension triggers the
infant to extend extremities, as if bracing himself
form falling; distinct in patients with hemiplegia and
cerebral palsy
Disappears by 6-9 months
Neck righting reflex: body turns to side where
head turns
Deep Tendon Reflex (DTR)
Appearance of a newborn: integument
 Ruddy complexion of elevated RBC levels
and low amount of subcutaneous fat
Other Findings:
 Acrocyanosis: pinkish trunk + bluish
extremities due to immature peripheral
circulation; appears during the 1st 24 to 48
hours of life.
 Physiologic jaudince/
hyperbilirubinemia: yellowish discoloration
of the skin due to RBC destruction occurring
during the 2nd and 3rd day of life.
 Harlequin sign: with the child in side-lying
position, the dependent side of the body
remains pinkish while the nondependent
side becomes bluish; caused by immature
peripheral circulation.
 Hemangiomas: vascular tumor of the skin.
 Nevus flammeus/ Portwine stain: macular
purple/ dark-red lesion present on the face
and thighs at birth
 Stork’s beak marks/ telangientasia:
lighter pink patches of nevus flammeus
found at the nape.
 Strawberry hemangioma: elevated areas
formed by immature capillaries of
endothelial cells; may appear up to 2 weeks
after birth; fades with time; associated with
high estrogen levels during pregnancy.
 Cavernous hemangioma: dilated vascular
spaces similar to strawberry hemangiomas
in appearance; do not fade with time and
may be present in internal organs, making
them prone to bleeding.
Mongolian spots/slate gray nevi: collection of
pigmented cells/ melanocytes manifested as slate
gray patches across the buttocks, sacrum, arms,
and legs.
Vernix caseosa: white, cream cheese-like
substance that served as skin lubricant in utero;
color similar to amniotic fluid; not to be rubbed off
skin.
Lanugo: fine downy hair found in newborn’s
shoulders, back, and upper arms; more in
premature infants; disappears by 2 weeks of age.
Desquamation: peeling of skin within 24 hours
after birth; normally occurs in the palm of the hands
and soles of the feet
Milia: pinpoint white papules at cheek or at nose
bridge of the newborn; disappears by 2-4 weeks.
Erythema toxicum: newborn rash appearing at 1st
– 4th day of life up to 2 weeks; has no pattern,
miniscule, and is sporadic in appearance.
Forceps marks: circular or linear contusion
matching the rim of the blade of the forceps on
infant’s cheek; disappears in 1-2 days.

 Molding: temporary alteration in fetal head
shape due to fitting on cervical contours
during delivery.
Other findings:
 Cephalhematoma: collection of blood
beneath the periosteum caused by pressure
on fetal head during delivery; may cross
suture lines; reabsorbed weeks after birth;
may cause jaundice.
 Caput Succedaneum: edema in the scalp
on the presenting part of the head during
delivery; crosses suture lines; disappears in
3rd day of life.
 Craniotabes: softening of the cranial bones
due to pressure on fetal head against the
mother’s pelvic bone in utero.
Breastfeeding
 Prolactin: hormone responsible for milk
production
 Oxytocin: hormone responsible for let-down
reflex/milk ejection
 Colostrum: thin, watery, yellowish fluid
produced since the 4th month of pregnancy,
ingested by breastfed
 children during the 1st 3-4 days of life; high
in protein, low carbohydrate and fat.
 True/mature breastmilk: appears on 10th day
after birth
 (eyes) Subconjuctival hemorrhage: rupture
of conjunctival capillaries due to pressure
on fetal head on birth; disappears 2-3
weeks after birth.
 (Mouth) Epstein pearls: small, round,
glistening, well-circumcised cysts on palate
due to calcium deposition in utero.
 (chest) Witch’s Milk (Galactorrhea): thin,
watery fluid form the breast of a newborn as
an effect of residual maternal hormones in
fetal circulation.
 Abdomen is protuberant
 Bowel sounds may be heard within an hour
after birth
 Drying of the umbilical cord occurs 2-3 days
after birth.
 It falls off around 6-10 days after birth.
 Kidney is palpated within the first few hours
after birth to assess for renal agenesis
(absence of kidneys).
ANOGENITAL AREA
 Pseudomenstruation may occur in newborn
girls because of maternal hormones in
circulation.
 Cryptorchidism may occur as a result of
testicular agenesis, ectopic testes, or
undescended testes
 (extremities) Presence of Simian crease
suggests chromosomal aberrations.
 Expect newborn to have flat soles and
bowed legs
ballard’s scale of gestational age
 Used in assessing child’s gestational age;
also applicable for premature neonate and
neonates with miscalculated gestational
age.
 Neuromuscular Maturity
 Physical Maturity
REPRODUCTIVE HEALTH LAW
WHAT IS RA NO. 10354?
An act providing for a national policy on
Responsible Parenthood and Reproductive Health”
GUARANTEES OF THIS LAW
 Access to services on Reproductive Health and
Family Planning
 Maternal health care services
 RH and sexuality education for the youth
 Regular funding
RH LAW PROVIDES
 Midwives for skilled birth attendance
 Emergency obstetric care
 Hospital-based family planning - Section 18
 Contraceptives as essential medicines CHILDREN
 Reproductive health education - Healthier children
 Employees’ responsibilities ADOLESCENTS
 Capability building of community-based - Sexuality education
volunteer workers
- Prevent teenage pregnancy
RH LAW UPHOLDS
- Decrease incidence of HIV
Section 2
 Universal basic human right
To equality and nondiscrimination
To sustainable human development
To health
To make decisions
 Family
Gender equality, gender equity and women
empowerment
Universal access to RH care services
Promote openness to life: Provided, that parents
bring forth to the world only those children whom
they can raise in a truly humane way
 Section 2
 Universal basic human right
 To equality and nondiscrimination
 To sustainable human development
 To health
 To make decisions
 Family
 Gender equality, gender equity and women
empowerment
 Universal access to RH care services
 Promote openness to life: Provided, that
parents bring forth to the world only those
children whom they can raise in a truly humane
way
     JOSE ALEXAN

WHO CAN BENEFIT FROM THIS LAW?

WOMEN
- Address unmet need for family planning
PWDs