CONCEPTS OF GROWTH AND DEVELOPMENT

Definition of Terms

• GROWTH - physical change and increase in size

- measured QUANTITATIVELY
- ex: eight, weight, bone size, dentition, etc.

• DEVELOPMENT - increase in the complexity of function and skill progression

- measured QUALITATIVELY
- the capacity and skill of a person to function
- "the behavioral aspect of growth"
- ex: ability to work, to run, and to talk
- Synonyms
MATURATION / DIFFERENTATION

PRINCIPLES OF GROWTH AND DEVELOPMENT:

1. Growth and development are continuous processes from conception until death+ womb to
tomb
2. Growth and development proceed in an orderly sequence.
3. Different children pass through the predictable stage at different rates.
4. All body systems do not develop at the same rate.
5. Development is cephalocaudal.
6. Development proceeds from proximal to distal body parts.
7. Development proceeds from gross to refined skills.
8. There is an optimum time for initiation of experiences or learning.
9. Neonatal reflexes must be lost before development can proceed.
10. A great deal of skill and behavior is learned by practice.

FACTORS INFLUENCING GROWTH AND DEVELOPMENT:

1. Genetic Influences
1.1 physical characteristics
1.2 gender-related characteristics
1.3 race and cultural influences
2. Environmental Influences
2.1 quality of nutrition
2.2 socio-economic levels
2.3 parent-child relationship
2.4 ordinal positions in the family
2.5 health
PERIODS OF GROWTH:

PERIOD OF GROWTH TIME RANGE

I. Prenatal 0 – 280 days
Ovum 0 – 14 days
Embryo 14 days – 9 wks
Fetus 9 wks - birth
II. Natal
Premature/Preterm 23 – 37 weeks
Mature/Term 37 – 42 weeks
III. Postnatal
Neonate 0 – 28 days
Infant 0 – 1 year
Toddler 1 – 3 years
Preschooler 3 – 6 years
School Age 6 – 12 years
Adolescence 12 – 18 years

GROWTH AND DEVELOPMENT THEORIES:

I. PSYCHOSEXUAL THEORY (by Sigmund Freud)

- Freud proposes that the underlying motivation to human development is an energy form
or life instinct called LIBIDO.
- Unconscious mind is the mental life of a person of which the person is unaware.
- Proposed concepts like:
* ID - developed during infancy
- "I know what I want and 1 want it now!”
- Pleasure principle
* EGO - developed during toddler period
- "I can wait for what I want!"
- reality principle
- balances the id and superego
* SUPEREGO - developed during preschool period
- "I should not want that!"
- Conscience
- Defense mechanisms are the adaptive mechanisms of an individual as a result of conflicts
between inner impulses and the anxiety that attends these conflicts.

AGE RANGE GROWTH PERIOD STAGE/S

0 – 18 months Infancy Oral Stage
1 8 months – 3 years Toddler Anal Stage
3 – 6 years Preschool Phallic. Oedipal Stage
6 – 12 years School Age Latency Stage
12 – 18 years Adolescence Genital Stage
- If the individual does not achieve a satisfactory resolution at each stage, the personality
becomes FIXATED at that stage.

II. PSYCHOSOCIAL THEORY (by Erik Erikson)

- Reflects both positive and negative aspects of the critical life periods
- Erikson believes that the greater the task achievement, the healthier the personality of the
person; failure to achieve a task influences the ability to I achieve the next task.
- Resolution of the task can be complete, partial or unsuccessful.

AGE RANGE GROWTH PERIOD STAGE/S

0 – 1 year Trust vs. Mistrust Optimism
1 – 3 years Autonomy vs. Shame & Doubt Self-Control/Will Power
3 – 6 years Initiative vs. Guilt Direction & Purpose
6 – 12 years Industry vs. Inferiority Method & Competence
12 – 18 years Identity vs. role Confusion Devotion & Fidelity

III. COGNITIVE THEORY (by Jean Piaget)

- Cognitive development refers to the manner in which people learn to think, reason, and
use language.
- It involves a person's intelligence, perceptual ability, and ability to process information.
- Cognitive development represents a progression of mental abilities from illogical to logical
thinking, from simple to complex problem solving, and from understanding abstract
concepts

Stage of Development Age Span Nursing Implications

Sensorimotor
Neonatal reflex 1 mo Stimuli are assimilated into beginning mental images.
Behavior entirely reflexive
Primary circular 1-4 mo Hand-mouth and ear-eye coordination develop. Infant
reaction spends much time looking at objects and separating self
from them. Beginning intention of behavior present (the
infant brings thumb to mouth .for a purpose: to suck it).
Enjoyable activity for this period: a rattle or tape of parent's
voice:
Secondary circular 4-8 mo I
reaction Infant learns to initiate, recognize, and repeat pleasurable
experiences from environment. Memory traces are present;
infant anticipates familiar events (a parental coming near
Coordination of 8-12 mo him will pick him up). Good toy for this period: mirror: good
secondary reactions game: peek-a-boo
Infant can plan activities to attain specific goals. Perceives
that others can cause activity and that activities of own body
are separate from activity of objects. Search for and retrieve
toy that disappears from view. Recognizes shapes and sizes
of familiar objects. Because of increased sense of
Tertiary circular 12-18 mo separateness, infant experiences separation anxiety when
reaction primary caregiver leaves. Good toy for this period: nesting
toys (i.e., colored boxes),
Child is able to experiment to discover new properties of
 objects and events Capable of space perception and time
Invention of new 18-24 yr perception as well as permanent. Objects outside self are
means through understood as causes of actions. Good game for this
mental combinations period: throw and retrieve.
Transitional phase to the preoperational thought period,
Uses memory and limitation to act. Can solve basic
Preoperational 2-7 yr problems; foresee maneuvers that will succeed of fail.
Thought Good toys for this period: those with several uses, such as
blocks, colored plastic rings.
Thought becomes more symbolic; can arrive at answers
mentally instead through physical attempt. Comprehends
simple abstractions but thinking is basically concrete and
literal. Child is egocentric (unable to see the view point of
another). Displays static thinking. (Inability to remember
what he or she started to talk about so that at the end of a
sentence the child is talking about another topic). Concept
of time is now and concept of distance is only as far as she
or can see. Centering or focusing on a single aspect of an
object causes distorted reasoning. No awareness of
7-12 yr reversibility (for every action there is an opposite action) is
Concrete Operational present. Unable to state cause-effect relationships,
Thought categories or abstractions. Good toy for this period: items
that require imagination, such as modeling clay. Concrete
operations include systematic reasoning. Uses memory to
learn broad concepts (fruit) and subgroups of concepts
(apples, oranges). Classifications involve sorting objects
according to attributes such as color; seriation in which
objects are ordered according to increasing or decreasing
measures such as weight; multiplication, in which objects
are simultaneously classified and seriated using weight.
Child is aware of reversibility, an opposite operation or
continuation of reasoning back to a starting point (follows
a route through; and then reverses steps). Understands
conservation, sees constancy despite transformation
(mass or quantity remains the same even if it changes
12 yr shape or position). Good activity for this period: collecting
Formal Operational and classifying natural object such as native plants,
Thought seashells, etc. Expose child to other viewpoints by asking
questions such as, "How do you think you'd feel if you
were a nurse and tell a boy to stay in bed?"
Can solve hypothetical problems with scientific reasoning;
understands causal and can deal with the past, present, and
future. Adult or mature thought. Good activity' for this
period: "talk time" to sort through attitudes and opinion

IV. MORAL THEORY (by L. Kohlberg)

- Moral development is a complex process not fully understood since it involves learning
what ought to be and what ought not to be done
- The term “moral” means relating to right and wrong
- Moral development is the pattern of change in moral behavior with age.

V. SPIRITUAL THEORY (by James Fowler

- The spiritual component of growth and development refers to the individual’s
understanding of their relationship with the universe and their perceptions about the
direction and meaning of life
- Fowler believes that faith is an active “mode-of-being-in-relation” to another or others in
which we invest commitment, belief, love, risk and hope.

DEVELOPMENT OF CHILDREN'S CONCEPTS AND FEELINGS ABOUT DEATH—I

Age
0 - 2 years No concept of death
Developing awareness of separation and loss
First death-related perceptions? “All gone”; “peek-a-boo” games
3 – 5 years Egocentric orientation: animism, magical thinking, & artificialism
Conceive death as continuous with life; not final
Death understood as separation like travel (& thus temporary, reversible,
cyclical) or as a diminished life-form like asleep (& thus on-going functioning
at a reduced level).
Death applies to others, i.e., is not personal
Curious for specific, concrete information
May moralize about death, i.e., punishment and responsibility
6 – 9 years Gradual decentering in ego-orientation; recognition of law of conservation or
permanency
Growing understanding of death as final and irreversible
Continued subjectivity in viewpoint; others may die, but death is capricious and
personal death is avoidable
May personify death: angel, grim reaper, skeleton, bogeyman
10 & older Death understood as final, universal, and inevitable
Applies to all of us, including me; i.e., death is personal (but distant
Death is an internal reality, not an external force
Adolescence Increasingly abstract and generalized thinking
Deepening of mature or adult conceptions of death
Determination of personal philosophical or religious view of life, death, and their
meaning
Emphasis on present living and future promise.
 NEONATE
Immediate Care:

1. Establish and maintain a patent airway

- Never stimulate to cry unless secretions have been drained out.
- Head lower than the rest of the body (except in increased ICP)
- Suction secretions properly:
1. MOUTH before NOSE (prevent inhalational reflex)
2. AVOID PROLONGED (>10 min) and DEEP SUCTIONING (stimulates vagus nerve →
BRADYCARDIA
3. OCCLUDE ONE NOSTRIL AT A TIME → Check for struggle (Choanal atresia) *** Note:
Newborns are obligate nasal breathers!

2. Maintain appropriate body temperature.

- Body temperature is about 37.2°C at the moment of birth (confined in an internal body
organ
- There's heat loss due to immature temperature-regulating mechanisms.
- COLD STRESS → due to large.' losses of heat (Convection, Conduction, Radiation,
Evaporation)
Effects:
1. Metabolic acidosis (breakdown of brown fat found in INTRASCAPULAR AREA,
THORAX and PERIRENAL REGIONS)
2. Hypoglycemia (due to use of glucose stored as glycogen)
Prevention:
1. Dry' the newborn immediately.
2. Wrap him with warn sheets
3. Put him under a droplight.

Immediate Assessment:
1. APGAR score

I min score = cardiovascular and respiratory status

5 min score = neurologic status

Criteria 0 1 2
A – ppearance Blue Acrocyanosis Pink
(color)
P – ulse 0 < 100 100 and above
(Heart Rate)
G – rimace No response Grimace; weak cry Good, strong cry;
(Reflex Irritability) sneeze
A –ctivity Limp, flaccid Some flexion of Well-flexed
(Muscle Tone) extremities extremities
R- esp. Effort Absent Weak cry Good, strong cry

Score Interpretation:
0 - 3 Resuscitation ASAP!
4 - 6 guarded → Continuous monitoring & suctioning
 7 -10  Best possible condition

2. Gestational Age Assessment (BESTS)

Criteria 0.36 weeks 37-38 weeks 39 weeks & above

B – reast nodule 2 mm 4 mm 7 mm
E – ar lobe No cartilage Some cartilage Thick cartilage
S – calp hair Fine and fuzzy Fine and fuzzy Coarse and silky
T – estes/Scrotum Testes in lower sac; Intermediate; scrotum Testes pendulous;
scrotum with no rugae with some rugae scrotum with rugae
S – ole creases Anterior transverse Creases over anterior Entire sole covered
crease only 2/3 with creases

3. Ballard's Scoring

A. Neuromuscular Maturity
- Posture
- Square window
- Arm recoil
- Popliteal angle
- Scarf sign
- Heel to ear

B. Physical
- Skin
- Lanugo
- Plantar surface
- Breast
- Eye-ear
- Genitalia

4. Physical Examination

A. Vital signs
HR = 120 - 140/min (Apical) **Palpable radial pulse => Coarctation of Aorta
RR = 30 - 60/min (diaphragmatic, abdominal, quite irregular, rapid, quiet and
shallow)
BP = 80/46 → 1 00/50 mmHg after 10 days
Temp = must be maintained at 35.5°C - 36.5°C (rectal route. preferred to check patency
of anus)
B. Anthropometric measurements
Length = 47.5 - 53.75 cm (Ave: 50 cm)
HC = 33-35 cm (measure center of forehead and the prominence of occiput)
CC = 31-33 cm (measure at the level of nipples)
AC = 31-33 cm (measure at the level of umbilicus)
Weight = 6.5-7.5 lbs (3.0-3.4 kg)
** 5.5 lbs (2.5 kg) = low birth weight
** 5-10% physiologic weight loss (6-10 oz) during the 1st 10 days
 Reasons:
1. no maternal hormone influence
2. voids and passes stools
3. limited caloric intake due to colostrum (1513 days)

C. Skin
- Normally ruddy because of increased RBC concentration and decreased
amount of subcutaneous fats
- acrocyanosis mottling (normal in 24-48 hrs); HARLEQUIN SIGN
- generalized mottling (Cutis Marmorata) may be seen
- desquamation (drying of skin)

Abnormal skin findings:

1. Pallor - excessive blood loss; inadequate blood flow from cord; decrease iron stores;
blood incompatibility
2. Gray – infection
3. Jaundice (Use natural light and blanch skin on the chest or tip or the nose
- Inability to conjugate bilirubin (decreased GLUCORONY TRANSFERASE)
- Normal values:
Total Bilirubin 15.0 mg/dl
Direct Bilirubin 1.5 mg/dl
Indirect Bilirubin 13.5 mg/dl
** If value of total bilirubin = 10 to 12 mg/dl, start treatment
** If value of total bilirubin is >20 mg/dl = KERNICTERUS
- Physiologic jaundice: 2nd to 7'11 day
- Breastfed babies have longer physiologic jaundice because human milk has
PREGNANEDIOL → depresses glucoronyl transferase, a liver enzyme
- Estimates of indirect bilirubin:
Up to neck 8 mg/dl
Up to umbilicus 5-12 mg/dl
Up to knees 8-16 mg/dl
Up to ankles 11-18 mg/dl
Up to soles 15-20 mg/d1

- Treatment of Pathologic Jaundice:

1. Phototherapy (photoisomerization of indirect bilirubin)
- 10 pcs 20-watt daylight or blue fluorescent lights at 30 inches
above
- cover eyes and scrotum with an opaque mask
- monitor temperature
- adequate hydration
- turn q 2H to expose all body areas
- measure I & Q
2. Exchange transfusion

Common skin marks of the newborn:

1. Desquamation - peeling of skin; indicates post-maturity
2. Mongolian spots - bluish-black/slate gray pigmentation across the sacrum or
 buttocks; disappear by SCHOOL AGE.
3. Vernix caseosa - cheese-like material; serves as insulator
4. Lanugo - fine, downy hair at shoulders, back and upper arms; disappear by 2
weeks.
5. Milia - plugged or unopened sebaceous gland on the cheek or across the bridge of
the nose; disappear by 2-4 weeks
6. Nevi (Stork bites) - pink or red flat areas of capillary dilatation seen on upper lids,
nose, upper lip, nape and neck; disappears at 1st and 2nd year.
7. Erythema toxicum - aka fleabite.rash; pink papules with vesicles seen at nape,
back and buttocks; appears usually 2nd day; no treatment needed.
8. Nevus flammeus - aka portwine stain; red to purple in color; do not blanch on
pressure and do not disappear.
9. Strawberry hemangioma - elevated areas formed by immature capillaries and
endothelial cells; complete disappearance by 10 yrs old.
10. Cavernous hemangiomas - dilated vascular spaces; do not disappear with time.
11. Forceps marks - disappears in 1-2 days.

D. Head - forehead prominent; chin receding

1. Fontanelles - should be flat; not indented or bulging
Anterior (diamond-shaped) closes 12-18 months
Posterior (triangular shaped) closes 2-3 months.
2. Molding - some overlapping of sutures
3. Craniotabes - localized softening of the cranial bones caused by pressure of fetal
skull against the mother's pelvic bone; more common in firstborn infants
If found in older child → faulty metabolism or kidney dysfunction
4. Craniosynostosis - premature closure of sutures and fontanelles → MENTAL
RETARDATION.
5. Caput succedaneum vs. Cephalhematoma

Criteria Caput succedaneum Cephalhematoma

Cause Scalp edema Collection of blood between
periosteum and skull bone
Extent of Both hemispheres (Crosses
Does not cross sutures
Involvement sutures)
Absorption About 3 days Several weeks

E. Eyes (Assess by putting infant in upright position)

- tearless due to immature lacrimal ducts
- cornea is round
- pupil is dark
- temporary cross-eyed (STRABISMUS)
F. Ears
- The level of top part of the external ear should bean a line drawn from the inner
canthus to the outer canthus of the eye
- Low-set ears is found in kidney malfunction; Down's syndrome

G. Nose
- appear large for the face; no septal deviation
 - obligate nasal breathers

H. Mouth
- should open evenly when crying
- tongue appears large
- palate intact; lips should have no breaks
- EPSTEIN PEARLS: small, round glistening cysts on the palate (due to
hypercalcemia of the mother)
- NATAL TEETH- teeth upon birth if loose, should be extracted; Neonatal teeth
are teeth erupted BEFORE age 56 months
- Oral thrush: white or gray patches on the tongue or cheeks due to Candida
albicans (oral moniliasis)
I. Neck
- short and chubby; creased with folds
- thymus is palpable (triples at 3 yrs; stops growth and recedes by 10 years old)
- head should rotate freely
J. Chest
- should be symmetrical
- breasts may be engorged
- WITCH'S MILK: due to maternal hormones
- You may hear rhonchi
K. Abdomen
- slightly protuberant; dome-shaped
- if scaphoid → diaphragmatic hernia
- liver, spleen and kidneys are palpable
- umbilical cord - 2 arteries and 1 vein (stump falls off 6-1 0 days)
L. Anogenital region
- Pseudemenstruation-= this is thought to be due to the influence of the
maternal hormones
- epispadia, hypospadia, hydrocele
- oreskin should be retracted to test for phimosis and paraphimosis
- testes should be descended (If not, Cryptorchidism should be suspected)
- "wink reflex" sign of anal patency
M. Back
- appears flat when prone
- mass, hairy nebule or a dimple along axis – this is seen in Spina bifida
N. Extremities
- arms and legs are short and plump
- should move symmetrically → ERB DUCHENNE'S PARALYSIS
(Absent Mora reflex on affected arm)
Tx: Abduct the affected arm in external
rotation with the elbow flexed
- extra digits (polydactyly); fused (syndactyly)
- Simian line: a single palmar crease → Down’s syndrome
- Ortolani’s sign: congenital hip discoloration
Mgt: 3 diapers; carry astride on hips; hip spica
Systemic Evaluation
1. Cardiovascular System
Fetal accessory structures
Fetal accessory structures Functional Closure Adult structure
Foramen ovale 1 year Fossa ovalis
Ductus arteriosus 1 month Ligamentum arteriosum
Ductus venosus 2 months Ligamentum venosum
Umbilical arteries (2) 2-3 months Lateral umbilical ligament
Ligamentum teres
Umbilical vein (1) 2-3 months
(round
ligament of liver)

Blood values:
RBC = 6 M
Hgb = 17-18 gm %
Bct = 40-50%
WBC = 15,000 - 45,000/cu mm

2. GI System
Stools:
A. Meconium - sticky, tarlike, blackish-green, odorless
- mucus, vernix, lanugo, hormones and carbohydrates that accumulated during
intrauterine life.
B. Transitional stools - 2nd to 3rd day up to 10th day
- slimy green and loose resembling diarrhea to the untrained eye
C. Usual stools (10th day onwards)
Criteria Breastfed Infant Bottlefed Infant
Color Golden yellow Pale yellow
Consistency Mushy, soft Finn
Frequency of passage 3-4x/day 2-3x/day
Smell Sweet-smelling Malodorous
(increased lactic acid
which decreases
putrefactive organism in
stool)

3. Urinary System
- about 15 ml of urine per void
- females: form a strong stream when voiding
- males: small projected stream when voiding
- should void within 24 hours.

4. Autoimmune System
- difficulty forming antibodies against invading antigens up to 2 months
 - receives IgG from mother (passive natural immunity)
- no immunity from chickenpox and herpes simplex

5. Senses
- Touch – the most developed sense
6. Neuromuscular System

Neonatal Reflexes
Reflexes Disappearance
Rooting reflex 6 weeks
Sucking Reflex 6 months
Extrusion Reflex 4 months
Palmar grasp 6 weeks-3 months
Stepping (Walk-in-place/Dancing) Reflex 3 months
Placing (**anterior surface of leg) 3 months
Plantar, grasp 8-9 months
Tonic neck (Fencing/Boxer) Reflex 2-3 months
Moro reflex 4-5 months
Barbinski Reflex 3 months
Magnet Reflex 3 months
Crossed Extension Reflex 3 months
Trunk Incurvation Reflex 2-3 months
Landau Reflex (Parachute Reaction) 3 months
Bauer's (Crawling) Reflex 6 weeks
Blink Reflex (see objects 9-12" at midline) Do not disappear
Swallowing Reflex Do not disappear

Routine Care of the Newborn:

1. Give initial oil bath to cleanse the 'baby of blood, mucus and vernix.
2. Dress umbilical cord (70% alcohol or PNSS)
3. Crede's prophylaxis - against Ophthalmia neonatorum/gonorrheal conjunctivitis
a. 2 gtts 1 % AgN03 on lower conjunctival sac; flush with NSS
** Disadvantages:
1. chemical conjunctivitis
2. stain cheeks
3. no effect against Chlamydia
b. Erythromycin/Terramycin ointment
** inner to outer canthus; on lower conjunctival sac
4. Vitamin KI (Phytomenadione) administration → inject at vastus lateralis, middle third
** Clotting factors 2, 7, 9, 10
1.0 mg → full term infants
0.5 mg → pretern1 infants
5. Identification
** Bands; footprints

6. Feeding
NSVD = within 30 mins
C/S = within 3-4 hours
Initial feeding - with sterile water only; glucose is irritating to the lungs if aspirated (1 oz)
Subsequent feeding - per demand
RDA Calories 120 cal/kg BW or 50-55 cal/lb or 380 cal/day
Protein 2.2 grams/kg BW /day
Fluids 200z/day
Burp the baby 2X - middle and after feeding
Comparison of Human Milk and Cow's Milk:
Composition Human Milk Cow’s Milk
Calories 20 cal/oz 20 cal/oz
CEO High (Lactose) Low
CHON Low (Lactalbumin/Whey) High (Casein)
COOH Same (Linoleic Acid) Sam e
Minerals Low High
Iron Low Low

Table 6.1 COMPOSITION OF MATURE HUMAN MILK AND COW MILK

Composition Human Milk Cow Milk Composition Human Milk Cow Milk
Water (ml/dl) 87.1 87.2 Serine 69 160
Energy (kcal/dl) 75 66 Tyrosine 61 17S
Total solids (g/d!) 12.9 12.8 Major minerals per liter
Protein (g/dl) 1.1 3.5 Calcium (mg) 340 1170
Fat (g/dl) 4.5 3.7 Phosphorus (mg) 140 920
Lactose (g/dl) 6.8 4.9 Sodium (mEq) 7 22
Ash (g/dl) 0.2 0.7 Potassium (mEn) 13 35
Protein (% of total
Chloride (mEq) 11 29
protein)
Casein 40 82 Magnesium (mg) 40 120
Whey proteins 60 13 Sulfur (mg) 140 303
Nonprotein nitrogen
32 32 Trace minerals per liter
(mg/dl)
% Of total nitrogen) 15 6 Chromium (ug) --- 8-13
Amino acids (mg/dl) Manganese (ug) 7-15 20-40
Essential Copper (ug) .400 30
Histidine 22 95 Zinc (mg) 3-5 3-5
Isolellcine 68 228 Iodine (ug) 30 47
Leucine 100 350 Selenium (ug) 13-50 5-50
Lysine 73 277 Iron (mg) 0.5 0.5
Methionine 25 88 Vitamins per liter
Phenylalanine 48 172 Vitamin 1 (I.V.) 1898 1025
Threonine 50 164 Thiamine (ug) 160 440
Tryptophan 1.8 49 Riboflavin (ug) 360 1750
Valine 70 245 Niacin (ug) 1470 940
Nonessential Pyridoxine (ug) 100 640
Arginine 45 129 Pantothenate (mg) 1.84 3.46
Alanine 35 75 Folacin (ug) 52 55
Aspartic acid 116 166 BI2 (ug) 0.3 4
43
Cystine 22 32 Vitamin C (mg) 11
Glutamic acid 230 680 Vitamin D (LV.) 22 14
Glycine 0 11 Vitamin E (mg) 1.8 0.4
Proline 80 250 Vitamin K (ug) - 15 60
7. Bathing
- done anytime but not within 30 minutes after feeding
- sponge baths done until cord falls off

Common Health Problems Needs:

1. Constipation - more common among bottle-fed infants.
** Mgt:
- add more fluids or carbohydrates/sugar
- if anal sphincter is tight, dilate 2-3X daily with gloved little finger
2. Loose stools - management depends on cause
3. Colic
Causes:
- overfeeding
- gas distention
- too much carbohydrates
- tense and unsure mother
Mgt:
- feed by self-demand
- burp the baby twice during a feeding
- feed in upright position
- change milk formula if needed
- reduce sugar content
4. Spitting up - due to poorly developed sphincter
Mgt:
- feed in upright position
- position on right side after feeding
- burp more frequently
5. Skin irritation - may be due to poor hygiene, or irritation from urine, feces or laundry products
Mgt:
- expose to air
- careful washing and rinsing of skin
- starch bath (for Miliaria or prickly-heat rash)
6. Seborrheic dermatitis/cradle cap - involves sebaceous glands; due to poor hygiene
Mgt:
- apply mineral oil or Vaseline on the scalp at night
- giving shampoo bath in the morning
7. Clothing
- If mother feels warm, keep the baby cool.
- If the mother feels cold, keep the baby warm.
8. Sleep patterns
- need 16-20 hours of sleep a day

PREMATURE NEWBORN
- Born before the 37th week of gestation
SGA < 1Oth percentile
AGA 10-90th percentile
LGA > 90th percentile
- Characteristics:
1. Underdeveloped SC tissues; thin-skinned
Mgt: Incubator
Temp 33.3 - 34.4°C
Humidity 55-65%
Position on right side
2. Poikilothemlic
Take axillary’s temperature not rectal to decrease energy expenditure
3. Exaggerated weight loss
4. Frog-like position
5. CNS centers for respiration underdeveloped
02 inhalation (Never more than 40% → Retrolental fibroplasia)
6. Poor sucking mechanism for feeding
Feeding → OGT; determine residual milk
Special Problems:
1. Hyperbilirubinemia
2. Infection
3. Anemia (Iron stores given to baby during last 2 weeks of pregnancy)
4. Respiratory Distress Syndrome (Hyaline Membrane Disease) - lack of pulmonary
surfactants

POSTMA TURE NEWBORN

- Born after the 42nd week of gestation
- Characteristics:
1. "Old man's" facies
2. Weight loss
3. Dehydrated
 4. Chronic Hypoxia
5. Hypoglycemia
6. Long and thin
7. With cracked skin
8. Stained with meconium
9. Long nails; firm skull
10. Wide-eyed alertness

INFANCY

- Traditionally designated as the period 0 - 1 year of age.

- FIRST "period of rapid growth and development"
Growth and Development of the Infant
PHYSICAL GROWTH
A. Weight
- a simple reproducible growth parameter which serves as index of acute nutritional
depletion.
- birth weight doubles at 4-6 months of age
- birth weight triples at 12 months
- Quadruples at 2 ½ years
- Weight gain is approximately 1 lb/month or 6-8 oz/week for the 1st 6 mos; slightly less
for the next 6 mos.
- average weight:
male - 10 kg (22 lbs)
female - 9.5 kg (lbs)

- Formula:
BIRTH WEIGHT x Age in months + 600 grams= for the first 6 months
BIRTH WEIGHT X Age in months + 500 grams= for the 7 to 12 months
B. Height
- A reliable criterion for growth since this is not affected by excess fat or fluid.
- reflects growth failure and chronic under nutrition
 - 50% increase of the birth length during the 1st year
- average height: 30 inches (76.2 cm) at 1 year old
- growth is apparently in the trunk during the early months; lengthening of the legs
happens during the 2nd half of the 1st year
- Should be taken with the child lying supine or standing erect against measuring board.
- Summary of height pattern:
0-3 mos 9 cm
3-6 mos 8 cm
6-9 mos 5 cm
9-12 mos 3 cm
25cm
C. Head Circumference
- a reflection of rapid brain growth
- at the end of 1 st year, brain has already reached 2/3 of adult size
- head may have some asymmetry due to "persistent position" for sleep
- Pattern of growth:
1st 4 mos ½ inch per month
Next 8 mos ¼ inch per month
D. Body Proportion
- Mandible (lower jaw) becomes more prominent
- Head circumference becomes equal to chest circumference @ 6 mos
- Abdomen still protuberant .
- Start of development of vertebral curves (cervical, thoracic, lumbar) - there is lengthening of
lower extremities during the last 6 mos which Readies the child for walking
E. Body Systems
1. Cardiovascular System
- HR = 100-120 beats per minute
- BP = 80 - 100 mmHg
40 – 60
- physiologic anemia occurs because:
a. fetal RBC's life span is through and new replacement is not adequate yet
b. serum iron levels decrease since iron stores established in utero are already
used up
c. fetal hemoglobin is converted to adult hemoglobin (5-6 mos)
2. Respiratory System
- RR = 20-30 cycles per minute
- tubal cavity of the resp. tract is still small and mucous production still inefficient
- thoracic index (transverse: anteroposterior diameter) = 1.25
3. GI System
- digestion of CHON is adequate
- low amylase (until 3rd month)
 - low lipase (until 12th month)
- liver function is immature:
a. decreased conjugation of drugs
b. decreased storage of CHO, CHON and vitamins
- swallowing coordination is not developed until about 6 months
- extrusion reflex disappears at 3-4 months
- drinking from cup rather from the breast or bottle @ 8-10 mos
4. Immune System
- functional @ 2 mos
- produce IgG and IgM by 12 mos
- IgA, IgD, IgE are not plentiful even until preschool period
5. Temperature Regulation
- shivering is possible by 6 mos (increases muscle activity and warmth)
- there is development of additional adipose tissues which serve as insulators
- brown fat decreases in amount
6. Other Systems
- Kidneys remain immature and not as efficient in eliminating body wastes.
- Endocrine system remains immature ~ not able to react to STRESS efficiently.
7. Fluid Balance

COMPARTMENTS INFANT ADULT

Intracellular 40% 40%
Extracellular 35% 20%
• The higher the EC, the more prone to dehydration should illnesses like diarrhea occur.
8. Dentition
-1st tooth erupts @ 6 mos (LOWER CENTRAL INCISORS)
- Slightly earlier in girls that in boys
- RULE: No. of teeth = (age in months) - 6
- Some newborns may be born with teeth (called NATAL TEETH) or have teeth erupt in the 1
1st 4 weeks of life ( called NEONATAL TEETH) which occurs in 1 :2000 infants.
- if tooth is fixed firmly, it might as well not be removed; if loose, it mustbe removed to prevent
aspiration.
DEVELOPMENTAL MILESTONES
(Motor Development, Socialization, Language, Play)

Motor development progress systematically during the 1st year that reflects the principles
of cephalocaudal development and gross to fine motor development. Control proceeds from head
to trunk to lower extremities in progressive, predictable sequence. The Denver developmental
screening test is the best known and most widely used screening test that focuses on four
important developmental areas: PERSONAL-SOCIAL, FINE MOTOR ADAPTIVE, LANGUAGE AND
GROSS MOTOR. The DDST is used up to age 6 years
Two (2) Major Areas of Motor Development Assessment:
A. GROSS MOTOR
- Ability to accomplish large body movements
- Infant is observed in four (4) positions: ventral suspension, supine. prone, and sitting.
B. FINE MOTOR
- Measured by observing or testing prehensile ability (ability to coordinate hand
movements)
In addition to gross and fine motor skills that are developing at this time, language,
socialization and play behaviors also mark the major milestones during this age group.

PROMOTING SENSORY STIMULATION

VISION - Teach parents to make eye-to-eye contact with the infant to
stimulate vision and to promote socialization.
- Infants enjoy mobiles and crib mirror
- Photos of family members may be posted near the baby's crib.
HEARING - Infant's toys should have soft, musical or cooing sounds.
- An audiotape of family voices might be soothing
Reminder of their presence when they are not around.
TOUCH - Clothes should feel comfortable and diaper should always be dry.
- Teach parents to handle the infant with assurance and with
gentleness.
- Kangaroo hold" promotes close physical contact.

TASTE - Infants turn away or spit out a taste they do not enjoy.
- Urge parents to make a mealtime for fostering trust as well as
supplying nutrition.
- Feedings should be at the infant's pace and the amount should fit
the child's needs and not the parent's idea how much should be
eaten.
- Solid foods may be introduced at 4-6 mos in the following
sequence: cereals, fruits, vegetables, meats, the eggs.
- New foods should be introduced one at a time so that the child can
become accustomed to one new taste before another is tried.
- This also lets parents detect adverse reactions, such as allergy to a
new food.

SMELL - infants smell accurately within 1-2 hours after birth.

- Infants draws back from irritating smell and enjoys pleasant
odors like that of the breast milk .
- teach parents to be alert to substances that cause sneezing when
sprayed into the air, such as room deodorizers or cleaning
compounds, and to keep irritating odors from the child’s
 environment.

INFANT’S DAILY ACTIVITIES

A. BATHING
- An infant does not need a daily bath except in very hot weather.
- Bath serves many functions:
a. to promote cleanliness.
b. to provide opportunity for the baby to exercise and kick.
c. to give parents time to talk, touch and communicate with the
baby.
d. to give the baby the opportunity to learn different textures and
sensations.
B. DIAPER – AREA CARE
- Good diaper-area hygiene means not to allow an infant to wear soiled diapers for a lengthy
time.
- Diapers should be changed frequently.
- Skin should be washed thoroughly with water and mild soap.
- Petroleum jelly or A&D ointment may be used as prophylaxis.

C. CARE OF THE TEETH

- Fluoride is important in proper tooth development and prevention of tooth decay. Water
level should have 1 ppm Fluoride to protect the tooth enamel.
- Teach parents to begin "brushing" even before teeth erupt by rubbing apiece of gauze over
the gum pads.
- Toothpaste is not necessary.
D. DRESSING
- Clothes should be easy to launder and simply constructed
- Type of clothing should suit infant’s activity level
E. SLEEP
- Infants need 10-12 hours of sleep a night and one or several naps during the day.
- Caution parents not to place pillows to avoid possibility of suffocation.
F. EXERCISE
- The infant benefits from outings in a carriage or stroller, as sunlight provides a natural
source of vitamin D.
- Early mornings and late afternoons are the best times for the infant to be outside.
- Use of infant walkers must be closely supervised.

PARENTAL CONCERNS AND PROBLEMS RELATED TO INFANCY

1. Teething
2. Thumb sucking
3. Use of Pacifiers
4. Head Banging
5. Sleep Problems
6. Constipation
7. Loose Stools
8. Colic
9. Spitting up
10. Diaper Dermatitis
11. Miliaria
12. Seborrhea
13. Baby-Bottle Syndrome

TODDLER
- Considered as the age from age 1 or 1 ½ years – 3 years, a period in which enormous changes
take place in the child and in the family as well
- The largely immobile and preverbal child now becomes a walking, talking child with a sense of
independence
PHYSICAL GROWTH
Physical growth actually begins to slow through the toddler makes great developmentally.
A. Weight
- Gains only about 5-6 Ibs.(2.5 kg)
- Decreased weight gain due to increased activity
B. Height
- Gains on 5 inches (12 cm) a year during toddler period
- Subcutaneous fat ("baby fat") begins to disappear
- Estimate adult height: multiplying by 2 at 2 years
C. Head
- HC = CC at 6 months to 1 year
- CC > HC at 2 years
- Head circumference increases only 7 about 2 cm during the 2nd year compared to about
12 cm during the 1st year
- Anterior fontanel (bregma) closes at 12 -18 months
D. Body Contour
- Prominent abdomen (LORDOSIS)
- With wide-stanced gait
E. Body System
E.1 Respiratory System
- Respiration slows slightly but remains to be abdominal
- The lumen of the tract increase progressively so that the threat of
Lower respiratory infection is less
E.2 Cardiovascular System
- HR slow from 110 to 90 beats/min
- BP increase to about 99/64 mmHg
E.3 Nervous System
- brain develops to about 90% of adult size
- complete myelination of spinal cord cause urinary and anal sphincter control
E.4 GI System
- stomach capacity increases to the point that the child can eat 3 meals a day
- stomach secretions become more acid ~ GI infections are less common
E.5 Immune System
- IgG and IgM antibody production becomes mature @ 2 yrs of age
- the passive immunity effects from intrauterine life are no longer operative
E.6 Dentition
- 8 new teeth (the canines and the first molars) erupt during the 2nd year
- All 20 deciduous teeth are generally present by 2 y;, to 3 years of age

Special Needs of the Toddler

A. Sense of Autonomy
- Favorite word: “NO”
- Child learns to be independent
- Understanding love of the child is shown by:
a. giving him all the freedom he can safety use
b. giving him all the love and help he needs to keep him safe in an environment
beyond his control
c. giving in which he feels himself to be focal point
B. Graded Independence/Negativism
- gives the child opportunity to make choices
- Independence may be denied for possible painful experience which may hinder a child to
try new skills because of fear these needs are met by:
a. Regulating the toddler’s activities which is an important part of his training is a
challenge to the adult
b. Providing safe environment for a gradually expanding area of growth
c. Avoiding use of pain and ridicule as a means of punishment or of prevention of for
bidden activities
d. Allowing the child to have certain amount of defiance, which is normal
 C. Love and Security
- Love enables the toddler to grow up and reach out for more mature goals because he
feels secure
- Love for the mother decreases; attachment to a loving father increases.
- “Security object” (e.g diaper, blanket, toy, etc.)

Specific Areas for Guidance

A. Toilet Training
- The child must begin accepting the “reality principle” (giving up an immediate
pleasure in order to gain another pleasure later.)
- Toddler must give up the pleasure of excreting where and when he wishes in order to
gain his mother‘s approval.
Requisites for Toilet Training
1. Physiology readiness
1.1 Sphincter control – myelination of nerve tract occurs at around 15 – 18 months of age
(MOST IMPORTANT REQUIREMENT)
1.2 Recognizes the urge and with ability to stand and walk to the bathroom and manage
clothing
2. Psychological readiness
2.1 Understands the act of elimination
2.2 Ability to verbally communicate need to defecate or urinate
2.3 Mother or caretaker must be able to recognize verbal behavior
3. Desire to please the mother
Schedule/Timing of Training
15 – 18 moths start of training
18 mos – 24 mos bowel control
2 –3 years daytime bladder control
3 – 4 years nighttime bladder control

Principles of Toilet of Training

1. Bowel training should be started before bladder training. Bladder training is done 1 or
more months after fairly well established bowel training.
2. Training should not be accomplished during illness.
3. Consistency – observe usual time for defecation
4. Firm but not strict training should be done (<10 minutes).
5. Positive maternal attitude – when successful, the child should be praised and cuddled; if
not, she should not show any disapproval.
6. Child should feel secure when seated on the chair or toilet bowl. NEVER FLUSH TOILET
WHILE CHILD IS SITTING ON IT!
7. Child should not be given food or toys during training as it distracts him.

B. Delayed Speech
- A normal child will begin to speak by 15 months of age.
- If by 2 years, he is not able to speak, cause of the delay must be investigated.

D. Ritualistic Behavior
-Common between ages of 2-4 years
- Done to master skills

Intervention
1. Adults should recognize these rituals in such phases as:
a. Bathing – use of a face towel
b. Eating – use of bib, own utensils
c. Sleeping – taking a favorite toy a blanket to bed with him
2. Show other ways of doing things.

E. Temper Tantrums
- Occur when a child cannot integrate his interval impulses and the demands of reality
- He is frustrated and reacts in the only way he knows by violent body activity and crying
Causes
1. In the hospital – fear of the unknown
2. Adult refuses to grant a request
3. When the child is tired, before bedtime or naptime or during a tiring trip or visit.
4. When mother says, “No!” too frequently with regards to getting dirty, using a spoon, running,
etc.
5. As a response to difficulty in making choices or decisions
6. When the child is under pressure such as toilet training

Interventions
1. Remove him from immediate cause of tantrum with the adult whom he knows loves him.
2. Be calm and be patient. Do not force attention upon him, until he indicates he is ready for the
comfort of knowing he is loved.
3. He should not be given extra attention but should be observed from self-injury or anything in
the environment which may be a source of injury to him
4. Avoid restraining the child

Care after a Tantrum

1. Make few comments of his behavior
2. He should not be punished
3. Wash face and hands if he cooperates
4. Give a toy to divert attention

Prevention of Tantrums
1. The mother should try to show him better ways of solving his problems and provide more
socially acceptable outlet for his anger and frustration.
2. He should be helped to release his tension in a socially approved way such as physical
exercise going outdoors, gardening etc.

F. Dawdling
- Slowness in carrying out request the child gradually learning the differences between right and
wrong. He cannot decide which of the two actions to take.
- Occurs when:
a. The task being is too difficult will end failure
b. He tries to avoid a task he knows will end in failure
- Handle this problem by giving specific instructions. When the child learns through
experiences which action he should take, he will be able to make decisions more wisely
are quickly

Basic Needs of the Toddler

A. Bathing
- Time depends on the mother and the child’s wishes
- May be given before and evening meal, at bedtime because
it relaxes child and helps him to sleep.
- Toddlers enjoy bath time so that mother must proved to during the bath
B. Clothing
- Toddlers need clothing that can be changed quickly because they can’t stand still for long
- Criteria for clothing:
1. Light or bright in color
2. Large and easily managed buttons and snaps placed within easy reach of the child
3. Warm but not too bulky
4. Easy to put on and remove
5. Shoes should be wide enough and long enough, have pliable thicker soles,
conform to the shape of the foot, straight along

C. Vocabulary building
NOUNS → VERBS → ADJECTIVES → ADVERBS → PRONOUNS

D. Discipline
- GOAL: Establish Self-control
Principles
1. Immediately after a wrongdoing
2. Consistency and firmness
3. Disapproval of the behavior and NOT of the child
4. Positive Approach
5. Allow child to explain; explain the reason for your disciplining him.
6. Safety in disciplining
7. Provide physical care after so that DOUBT will be erased.
8. Withdraw privileges and NOT BASIC NEEDS (i.e. not sending child to sleep without dinner).

Forms of Discipline
1. Ignoring (BEST FOR TEMPER TANTRUM)
2. Redirecting child’s attention
3. Time-out
4. Corporal punishment (controversial)
5. Explaining and reasoning, reprimanding and loss of privileges for older children

Effects of good discipline (3S)

1. Security
2. Self-control
3. Socially appropriate behavior

E. Dental Care
- Brush and floss daily (with parent’s help) – twice daily
- Proper oral hygiene and adequate diet are essential for tooth decay prevention
- 21/3 – 3 years as soon as all the deciduous teeth are out, he can have his
FIRST DENTAL VISIT
- If water is not fluoridated, give supplements: 0.25 to 0.5 day
- Limit concentrated sweets.
- Do not allow the child to carry a bottle of milk or juice to bed
-3 years: instruct to brush teeth after eating and at bedtime

F. Sleep and Exercise

- Depends on age, health, emotional tension, and activity during the day
- 12 – 14 hrs at night and 1-2 hrs of daytime/afternoon nap.
-Usually outgrows bedtime rituals by 3 years old

G. Play
- The toddler‘s “work”; REMEMBER that language of the child is PLAY
- PARALLEL PLAY
- Games: like throwing and retrieving games; selfish, possessive of toys
(Lack of interest in toys: DANGER SIGN)

Purpose of Play
1. Physical development
2. Social development
3. Therapeutic value
4. Educational
5. Moral values formation

Characteristics of Play of toddler

1. Free, spontaneous, active, no rules
2. Constructive

Selection of Play Materials

1. Based on likes/dislikes
2. No sharp edges
3. No small removable parts
4. No beads, marbles, coins
5. No flammable toys painted with lead (“BRAIN DAMAGE”)

Toys
- pull and pull toys
- cars and trucks
- balls
- building blocks
- stuff toys and dolls (security objects)
- play telephone (this is the stage of language training)
- play hammer, drums, pots and pans (an outlet of aggressive behavior)
- wood simple puzzles
- large crayons (can draw a circle at 3 years)
H. Nutrition
- Caloric requirements: 1,300 calories per day; 100 cal/kg/day
- "Physiologic anorexia"

Eating behavior of a toddler

1. The child may develop food preference.
2. He may even refuse food for a short time.
3. He may be demanding in what he wants to eat and dishes he uses and the way food is served.
4. He is slow and clumsy but he enjoys feeding himself.
5. He may wander away from the table

Development of Eating Skills

12 - 15 months drinks from a cup which he himself holds
15 - 18 months holds his own spoon with much spilling
24 months feeds himself fairly well
Specific Suggestions for Feeding
1. At 11/2 to 2 years, child can eat table food and 3 meals a day. 2. Serve food in small portions.
3. Chop or cut the food in small pieces.
4. The diet each day should be well balanced. (About 16 oz of
milk should be given daily).
5. Satisfy the child's appetite with nutritious foods.
6. A void sweets.
7. Give vitamins.
8. Do not force him to eat.
9. Allow the child to join others at the table.
10. Recognize ritualistic behavior.
11. Do not use food as reward (may cause obesity)

PRESCHOOL
- Traditionally defined to include 3-6 years of age.
- Physical growth slows considerably during the period but personality and cognitive growth are
substantial.
PHYSICAL GROWTH
- There is definite change in the body contour during the preschool years.
- The wide-legged gait, prominent lordosis, and protuberant abdomen of the toddler change into a
slimmer, taller and much more childlike proportions
- Major step found is the child's ability to learn extended language, which is affected not only by
motor but by cognitive development

A. Weight
- gains 4.5 lbs. per year
- slow growth rate
- appetite remains as it was during the toddler years
B. Height
- only minimal gain is noticed about 2-3.5" (6-8 cm) a year on the average
C. Head Circumference
- not routinely measured over 2 years of age
D. Body Systems
D.I Nervous System
- Handedness is beginning to be obvious
- There is relative ease in learning language because of the increased cognitive ability.
D.2 Lymphatic System
 - Lymphatic tissue begins to grow (ex: tonsils).
- IgG and IgA increase.
- Illness becomes more localized (an upper respiratory infection remains
localized in the nose without systemic fever).
D.3 Cardiovascular System
- "Physiologic splitting" or innocent murmurs may be heard on auscultation (due to
changing size of the heart in reference to the thorax).
- PR decreases to about 85 bpm.
- BP = 100/60 mmHg
D.4 Urinary System
- Bladder remains to be palpable above the symphysis pubis
- Voiding becomes frequent (9-10x a day)
D.5 Muscular System
- Muscles are noticeably stronger
- Many children exhibit "genu valgus" (knock-knees) which disappears with skeletal
growth
DEVELOPMENTAL MILESTONE

.PERSONAL-SOCIAL-
AGE MOTOR LANGUAGE
ADAPTIVE

Stands on one foot for

3 years Repeats six syllables, Understands taking turns.
at
for instance: "'1 have
least one second.
a little dog”
Copies a circle (from model,
Jumps from bottom stair. without demonstration).
Names three to more
Alternates feet going objects in a picture. Builds three-block pyramid.
upstairs.
Gives sex. ("Are you a Dresses with supervision.
Pours from a pitcher. boy or a girl?").
Puts 10 pellets into bottle in
30
Can undo two buttons. Gives full name. . seconds.
Pedals a tricycle. Repeats three digits Separates easily from mother.
(one of three trials).
Feeds self well.
Knows a few rhymes.
Plays interactive games,
such
Gives appropriate as "tag".
answer to: "What:
swims-flies-shoots-
boils-bites-melts"

Uses plurals.
 Knows at least one color.

Can reply to questions in at least

three word sentences.

May have vocabulary of 750 to 1,000

words (3-31/2 years).
4 years
Repeats ten-word sentences without
errors.
Stands on one
foot for at least Copies cross (+) without
five seconds (two demonstration.
of three trials Counts three objects, pointing
correctly.
Imitates oblique cross (x)

Draws a man with four parts.

Hops at least
twice on one foot.
Repeats three to four digits (4-5 Cooperates with other children in
Can walk heel-to- years). play.
toe for four or
more steps (with Comprehends: "What do you do if:
heel one inch or you are hungry, sleepy, cold?"
less in Dresses and undresses self (mostly
front without supervision). Brushes teeth,
Spontaneous sentences, four to five
of washes face
words long.
toe).
Likes to ask questions. Compares lines: “Which is longer?”

Can button coat

Understands prepositions, such as:
or dress; may
lace shoe on-under-behind, etc. ("Put the block Folds paper two to three times.
on the table.").
Can select heavier from lighter
Can point to three out of four colors object.
(red, blue, green, yellow).
Cares for self at toilet

Speech is now an effective

communicative tool

5 years

Knows age ("How old are you?").

Balances on one
foot for eight to
ten seconds.
Copies a square. Copies oblique
cross (x) without demonstration
Skips, using feet
alternately.

May print a few letters (5-5112

May be able to tie years).
a knot.

Catches bounced Draws a man with at least six

ball with identifiable parts.
hands (not arm) Performs three tasks (with one
in two of three command) for instance: “Put pen on Builds a six-block pyramid from
trials. table-close door bring me the ball.” demonstrations

Knows four colors. Transports things in a wagon

Define use for: Fork-horse-key-pencil,

etc. Plays with coloring set,
Constructions toys, puzzles.
Identifies by name: Participates well group play
Nickel-dime-peny.
G. Accident Prevention
- Accidents are the leading cause of deaths 1 - 5 years of age.
- Poisoning is a leading cause of morbidity.
Falls
1. Use stair guards; crib rails always up
2. Windows and door always screened
3. Supervise at playgrounds
4. Keep clothes properly cared for and fitted 5. Avoid slippery floors
Poisoning
1. Make sure you don't give medications as "candies."
2. Keep medications out of reach.
Burns
1. Cover electrical outlets.
2. Turn pot handles toward back of stove.
3. Do not leave unattended in bathtub, near stoves. 4. Keep electrical wires out of reach.
5. Teach child what "hot" means.
6. Check Bath water temperature.
Drowning
1. Teach swimming pool and water safety.
2. Do not leave child unsupervised near water or bathtub.
3. Have swimming pool fence and gates with childproof locks.
Cuts and Stabs
1. Keep knives out of reach.
2. Teach safety with sharp objects. 3. Lock up guns and powder tools.
4. Keep scissors away.

Common Fears of the Preschooler

A. Fear of the Dark
- Due to vivid imagination and undue stress.
- A stuffed toy by day becomes a monster in the dark.
Interventions:
1. Monitor possible stimuli for such fear (TV shows, adult discussions, . frightening stories).
2. Burn a dim night-light.
3. Reassure the child he is safe.
4. No sleep medications please!
B. Fear of Mutilation
- Child has intense reaction to injury.
- He cries not from the pain only but also from the sight of the injury.
- A void threatening the child about mutilation in order to discipline him.
- POSTPONE SURGICAL PROCEDURES UNLESS EMERGENCY
C. Fear of Separation or Abandonment
- Sense of time is distorted.
- Sense of distance is limited.
- Common causes: hospitalization and going to new school
Behavioral Problems of the Preschooler

A. Telling Tall Tales

- Arises from the child's overactive imagination.
- Help the child separate fact from fiction.
B. Imaginary Friends
- Make sure that child has exposure to "real" playmates.
C. Regression
- related to STRESS
- Ignore behavior and investigate the cause of stress.
D. Bruxism
- "Night grinding”.
- A way of "letting go" to release tensions and allows falling asleep.
- Identify and relieve source of anxiety.
- If extensive, crown of teeth becomes abraded
E. Broken Fluency
- "Secondary Stuttering"
- Repeated words/syllables
- 2 to 6 years of age may typically have some speech difficulty.
- Correction should not be emotional
Principles:
1. Do not label the child as "stuttering."
2. Listen with patience what the child is saying.
3. Talk to the child in a calm, simple way.
4. Protect space for him to talk if there are other children in the family.
5. Do not force the child to speak if he doesn’t want to.
6. Do not reward for fluent speech or punish him for confluent speech.

Play for the Preschooler

Importance:
1. The child learns to express feelings.
2. The child develops concern for his playmates.
3. By play, the adult gains a view into the child's world.
Kinds of Play: (ASSOCIATIVE PLAY)
- From solitary and parallel play, it shifts to simple forms of:
1. Cooperative play - when the child begins to exchange ideas with other children and
gradually interact with them.
2. Loosely organized play - activity which continuous but membership can changes
3. Social play - child plays with other children.
4. Organized play - emerges at latter part of the preschool period.
Toys
1. IMAGINATIVE - imaginary friends are normal at this stage
- provide "real" playmates
- provide costumes (Superheroes)
- "dress-up" games

2. CREATIVE - sand bags

- cutting and pasting tools
- water colors/coloring books
- play clay
- simple jigsaw puzzles

3. DRAMATIC/IMITATIVE - play house

- dolls puppets
- housekeeping toys
- "doctor or .nurse" sets
4. ACTIVE - wagons
- tricycle
- playground equipments
- skates

Special Needs of the Preschooler

A. Development of Initiative
Principles:
1. His parents and other adults in his environment must encourage his plans and the use of his
imagination.
2. They must limit punishment to only those acts, which are dangerous, morally wrong or so
socially unacceptable that the result would be unfortunate or harmful) the child or his family.
3. Parents should encourage the child's efforts to cooperate and let him share in the decisions
and responsibilities of family living.
B. Security and Independence
Principles:
1. The parents must show love for him, must teach him and guide him toward maturity.
2. From verbal interaction with parents, he learns how to express himself so that he can
communicate with others on verbal level.
3. In the home, he learns to assume more responsibility and more independence.4. The child
gains from the parents the knowledge he needs to grow up with. (e.g., knowledge on sex and
religion).
C.Guidance
Suggestions:
1. Limits to the child's behavior must be set and consistently maintained.
2. Suggestions, not commands, must be done in a positive manner.
3. The child is not spoken to in a such a way that he feels guilty or fearful rather, he is reassured
by the sense that he is being helped by his parents in solving his problems.
4. A choice of action may be given him only when he actually may decide which. of two or more
lines of behavior he may take.
5. Adults should not make the mistake of playing for the child. He is helped to make his own
activities.
6. He is allowed freely to create his own work.
D. Sex Information
General Principles:
1. Information on sex should be given in response to the child's interest in the subject but never
as facts, which have no connection with the family life.
2. The source of information is sincere and loving parents.
3. Parents should answer the child's questions directly and honestly, basing on the amount of
information given and the phraseology used on the child's physiologic and developmental level.
4. Information should be given promptly, frankly and unemotionally.
5. Emphasis is placed on the physical aspect of sex, not moral implications.
E. Religious Development
General Principles:
1. In answering questions, parents must have genuine understanding, be subjective and kind.
2. Child cannot be kept spiritually neutral.
3. The child does not follow any religion because he understands it rather; he accepts it because
it is expected of him to do.
Two (2) Methods of Religious Development:
1. Indoctrination
2. Letting the child follow the religion of his choice. Early training in the faith by parents is
suggested. The discussion of religion can be a shared experience between parents and the child.

The Preschooler and His Family

A. The Family Romance - OEDIPAL PERIOD
- The little girl becomes possessive of her father and competes with mother for father's love
(Electra Complex).
- The little boy may compete with father for mother's love (Oedipal Complex). - The parent of the
same sex provides a model for the child to imitate as he develops and matures.
- By the end of preschool, the boy no longer wants to take his father's place but simply wants to
belike the father; the little girl wants to grow up like the mother.
- The child becomes friends with both parents and the family becomes a meaningful love-object.
B. Tile Only Child and tile Adopted Child
- The only child is the object of parental relations in the home.
- The adopted child may be like the only child.
- It is considered best to tell the adopted child the truth before this status has any meaning to him.
C. Effect of tile Birth of a Sibling (Sibling Rivalry)
Reaction of the Child:
1. The child feels rejected and jealous. Jealousy is shown:
1.1 directly - open dislike for the baby or may love the baby more than normal; hostility;
derogatory remarks; hit the baby.
1.2 indirectly - may become clumsy in his contact with infant.
2. The child becomes hostile to mother:
2.1 attacks the mother
2.2 ignore mother
2.3 Hostile to other adult (teacher, father)
2.4 regress
Ways of meeting the Problem:
1. The baby's coming should be discussed with the child even though he is too young to
understand the changes.
2. The older child may be sent to nursery school to develop outside contact. . 3. Child should
never be left alone with the baby.
4. Give the child a pet doll and encourage her to take care of the doll just like what mother
does to the baby.
5. Discuss with the child the difference of his needs and the baby's.
6. The child may stay with father when mother must take care of the baby.
Special Problems of the Preschooler
A. Thumb sucking
Causes:
1. May have had too little sucking pleasure
2. Maybe a sign that the child feels unloved.
3. It may be an expression of dissatisfaction in life.
4. When pressure is exerted upon him to give up an activity
Approaches:
1. Parents must observe the child and provide a happier childhood experience for him.
2. At the time the child sucks his thumb, the parents should provide more love and security.
3. Find the basis of the basis of the problem.
B. Food Likes and Dislikes
Approach:
1. Preschoolers are influenced by example and expectation of parents in eating.
2. Children should not be coaxed, bribed, or forced to eat.
3. The child should be allowed sufficient time to eat -- distraction should be avoided. .
4. The child should be allowed to eat with the family.
5. Serve food attractively.
6. Mid-morning and afternoon snacks may be given
C. Enuresis (Bedwetting)
Causes:
1. Lack of toilet training
2. Too early, too severe or over training
3. Stress
4. Environmental factors (e.g. dark hallways)
Approaches:
1. Adults should not make an issue of bedwetting. Do not use bribes or punishments, or threaten
the child.
2. Give less fluid at night.
3. Adult should help the child achieve a positive attitude toward enuresis -- to want to stay dry and
develop confidence in his ability to control urination. .
4. Physician and parents should analyze the situation to determine the cause.
D. Encopresis
- Uncontrolled stool passages beyond the time when bowel control is expected
- Causes: rigid training, stress, emotional problems or pathologic conditions
E. Selfishness
Approach:
1. Adults can help the preschooler to learn to share with others if they let him have possession,
which both the adult and he recognize as his.
2. He can be allowed to decide whether to give or refuse to give his toy to another.
3. Help the child to enjoy playing with other children.
4. Expose the child to group play since it encourages habit of sharing.
E. Bad Language
Approach:
1. Adults should feel relaxed and not be worried or shocked.
2. The child should not be punished.
3. Substitute the bad word with more difficult word.
4. In nursery school - the teacher may suggest other words, use distraction or playing with
others.
5. Less attention is paid to use of the word.
F. Destructiveness
Causes: Much of the child's accidental destructiveness is the result of his boundless energy and
endless curiosity.
To avoid this:
1. The parents should remove valuable objects the child might break or damage.
2. Provide space for their child to play without danger of breaking and harming furniture of the
house.
3. Toys are apt to be given rough use. Parents should realize that material possessions do not
mean as much to a child as to adults. In the course of play the child may break or tear the toys
using them in way they were not intended - parents should put up certain restriction in the use of
toys - he will soon learn to value his own possessions and those of others. What he "values he
will learn to use with care."
G. Hurting Others
Causes:
1. He may be jealous or frustrated.
2. His behavior results from his mental state.
Approach:
1. The child should not be punished by having the same injury inflicted in him.
2. The child should not be forced to apologize to the child whom he hurt.
3. The child must not be made to feel rejected by the adult. The adult must take positive action
in situation in which the child is likely to hurt others.
4. The child should be helped to identify with the group accepting them and being identified
with them.
5. Play will serve an outlet of his feelings of frustrations with the group.
He must be praised for his achievement in the group.
H. Masturbation .
- Infants realize that a pleasant sensation accompanies handling of his genitals but this has no
significance to him and not accompanied by fantasies.
- Male preschoolers always assure themselves that the genitalia is not "lost."
- Adolescents masturbate to fulfill sexual urges, which in our culture generally do not have
socially approved release in heterosexual intercourse outside marriage.
Approach:
1. The child should not be punished; he should be helped to solve the problem that is causing
it.
2. The child should be given ample opportunity to find another more socially acceptable
pleasure outside his body.
3. He must be assured that he is safe in his parent's affection and should not be afraid or
ashamed.
4. Parents should answer all questions about sex.
5. Poor handling of the problem in the child is likely to result in fixation an autocratic level,
wherein the child seeks pleasure in himself rather in relation with others.
Two important aspects of masturbation that must be kept in mind:
1. Masturbation focuses a feeling in the genital region, this feeling is necessary for the health
functioning of men and women.
2. Shame and threats related to this activity can force children to repress their sexual feelings.
This might eventuate in impotence in the male and frigidity in the female.
Physical Care
Daily schedule of activities should be planned e.g. active play-quiet play and rest. The
child is gaining competency in self-care: He learns to feed himself without spilling, to dress and
undress, brush his teeth and is toilet trained. Mother should encourage him to use his abilities so
he'll be more independent.
Sleep
The child at this time should have a room or a portion of a divided room of his own.
Privacy in his sleeping is needed not only for sleeping but for social, sexual, gender identity,
fantasy and individual development. He needs a place to store his treasured possessions.
Sleep of 3 years old is disturbed at night because of frightening dreams due to his real or
imaginary daytime fears. He may sleep beside the room of a brother.
By 5 years he now may sleep quietly and peacefully but may still have nightmares.
Safety Measures
Preschoolers have more freedom than the toddler has. Playing outdoors alone, being
away from a safe home environment are some factors that may prone the child to more accidents.
Causes of Accidents:
1. Increased initiative and the desire to initiate the behavior of the adult which lead the
children into situations hazardous for them e.g. - falls.
2. They may play with matches.
3. They may turn on hot water
4. Increased freedom may result in playing around motor vehicles or swimming.
Approach:
1. Parents and adults should emphasize safety measures in terms they can understand. .
3. Teachers in the nursery school must provide a safe environment for the preschoolers.
• A void walking alone on lonely streets.
• To learn to know the local police.
• To refuse gifts and automobile rides from strangers.
• To give information about sex offenders.
• To know own complete name, address and telephone number of home and or
parent's place of work.
Health Supervision
- Purposes of visits to the health clinic every 6 months - 1 year:
1. Complete physical exam including tests for visual perception.
2. Advise mother on safety factors.
3. Appropriate immunization.
4. Dental care - teeth is brushed after eating and auditory
Nutrition
- Calories: 1700 cal per day /90 Kcal per kg per day
- Approach:
1. Serve meal using dishes; provide comfortaf.1le chair; and give small feedings.
 2. Consider likes and dislikes.
3. Parents should be models - e.g. enjoy eating during mealtime.
4. The child should not be forced to eat -- distraction should be avoided.
5. The child should not be permitted to nibble between meals.

Nursery School
Reasons why a child is sent to nursery school:
1. When he needs the educational experience to supplement what he receives at home.
2. When he needs the socializing experience with other children.
Values of Nursery School:
1. Provides growth and development and improves general health of the child.
2. Increases capacity for independence, his self-confidence and feeling of security

3. Broadens his appreciation of the avenues of self-expression through art, music and
rhythm.
Criteria for Selection of School:
1. qualification of teachers
2. proportion of teachers to children
3. health facilities
4. physical set-up
5. educational method

Preparation for Nursery School:

1. The mother should take him to the school to become familiar with the physical
surroundings. The child should meet his teacher.
2. After seeing the school, decision is made as to whether the child should attend school. He
makes a decision.
3. On the first day the mother should stay with the child and may continue until the child feels
secure.
 SCHOOL AGE
- Refers to children between the ages of 6 to 12 years.
- This is usually the first time that children are making truly independent judgments.
- The child of school age is more influenced by the attitudes of his friends.

PHYSICAL GROWTH
- School age children mature slowly but steadily.
A. Weight
- Annual average weight gain is approximately 3-5 lbs. (1.3-2.2 kg).
- Major weight gains occur @ 10-12 yrs for boys and 9-12 yrs for girls.
- Girls are usually heavier.
B. Height
- At 6 years, both boys and girls are about the same height.
- Before puberty, children of both sexes have a "growth between 10-12 yrs; and boys between 12-
14 yrs.
- Girls may well be taller than boys.
- Posture becomes erect.
C. Nervous System
- Brain growth is complete.
- Fine motor coordination becomes refined.
- Eye globe reaches its final shape at this time.
- The adult vision (20120) level is achieved.
D. Lymphatic System
- IgG and IgA reach adult levels.
- Lymphatic tissue continues to grow in size up until about age 9; the resulting abundance of
tonsillar and adenoid tissue in the early school years is often mistaken for disease during
respiratory illness.
- This tissue growth may also result in temporary conductive deafness from Eustachian tube
obstruction.
- The appendix is also lined with lymphatic tissue and the swelling of this tissue in the narrow
tube can lead to trapped fecal material and inflammation (appendicitis).
E. Cardiovascular and Respiratory System
- Left ventricle of the heart enlarges so as to be strong enough to pump blood to the growing
body. .
- Innocent heart murmurs may become apparent owing to the extra blood crossing heart valves.
- Pulse rate decreases to 70-80 bpm.
- BP increases to about 112/60 mmHg.
- Maturation of respiratory system leads to increased 02-C02 exchange which increases exertion
ability and stamina.
E. Dentition
- Deciduous teeth are lost at 5-7 years (Average: 6 yrs) and permanent teeth erupt.
- The average child gains 28 teeth between 6-12 years of age (central and lateral cupids; 1st, rd
and 3rd cupids; and 2nd molars).
- At 12 - all permanent teeth except the final molars
1. The age of dental caries - major problem of the stage.
Causes: poor nutrition, inadequate dental hygiene, increased intake of carbohydrates
and concentrated sweets.
2. Prevention of dental caries: good brushing and flossing, good nutrition, fluoridated
water, regular dental check-up.

Sexual Maturation
- At a set point in brain maturity, the hypothalamus transmits an enzyme to the anterior pituitary
gland to begin production of gonadotropic hormones, which activate changes in the testes and
ovaries.
- Timing of this maturity varies widely, between 10-14 years of age.
- Sexual Concerns:
A. Concerns of girls
• Females are usually conscious of breast development. A girl who is developing ahead of
her peers may tend to slouch or wear loose clothing to hide the fact.
• Other girls study themselves and wonder whether their breasts are going to develop
enough. Breast development is usually NOT symmetric.
• Hips become broader.
• As part of preparation for menstruation, girls should be told that vaginal secretions will
appear.
• Some girls already menstruate (MENARCHE).
B. Concerns of boys
• Boys become concerned of increasing genital size; testicular development precedes penis
growth.
• Males measure their 'manliness" by penis size, which can make a male who develops late
feel inferior.
• Hypertrophy of breast tissue (GYNECOMASTIA) occurs more often in stocky or heavy
boys.
• They have to be reassured that pubic hair growth comes first before appearance of chest
hair and beard.
• As seminal fluid is produced, boys may begin to notice ejaculation during sleep called
NOCTURNAL EMISSIONS (" Wet dreams").
Prepubertal Changes
A. Boys
1. Testes and Scrotum increase in size.
2. The skin over the scrotum changes color; it becomes reddened and stippled.
3. the breasts may enlarge slightly, but this growth disappears in a few months.
4. Sparse, downy pubic hair grows at the base of the penis.
5. The penis gradually becomes wider and longer.
6. The boy grows taller and his shoulders widen.
7. Axillary sweating begins.
B. Girls:
1. The pelvis and hips broaden.
2. The breast tissues develop and may be tender. At first, the
nipple is slightly elevated, @ 7Yr8 years of age. The areolae become somewhat
protuberant and enlarged between the ages of 9 and 11 years.
3. Axillary sweating begins.
4. The initial growth of pubic hair occurs at 8-14 years.
5. Vaginal secretions become milky and change from an alkaline
to an acid pH, and vaginal flora change from mixed to Doderlein's lactic
acid producing bacilli.

DEVELOPMENTAL MILESTONES
A. Gross and Fine Motor Skills
1. There is increased strength and physical ability,
very energetic,develops greater coordination and stamina.
2. Bone growth is faster than muscular and ligament growth;
susceptible to fractures; looks lanky.

6 years - "transition year"

- jumps, skips, hops well
- prints
- ties shoe laces well
- cuts and pastes well
7 years - "assimilative age"; quieting period
- rides a bicycle
- vision mature; hand-eye coordination develops completely
- psychosomatic illnesses are common
- can swim
- enjoys reading
8 year - "expansive age"
- writes rather than print
- More graceful movement
 - increased smoothness and speed
- since arms and legs begin to grow, may
- stumble on furniture or spill his milk at the table.

9 years - "on the go" constantly

- enjoys baseball or basketball

1 0 years - start of "pre-adolescent stage"

- begins to show secondary sex characteristic changes
- girls usually taller than boys
- some girls menstruate, thus decline activity

11 year - more active

- in constant motion; drumming fingers; tapping pencils or
feet (nervous energy)
- awkward because of pre-adolescent growth spurt

B. Language Development
1. With rapidly expanding vocabulary.
2. Likes name-calling, word games
3. With passwords/secret languages
4. With sense of humor; giggles a lot; laughs a great deal; enjoys dirty jokes.
C. Psychosocial Skills
1. School occupies half of his waking hours
a. friends/classmates more important than family
b. teacher becomes parent-substitute
c. school phobia - difficulty coping with school demands
2. Increasing social sensitivity
3. More cooperative, with improved manners
4. Capable of good deal of responsibility
5. Modest; enjoys privacy (starting a.! 10 yrs
6. With "hero-worshipping."

D. Cognitive Skills
1. Period of industry: likes to explore, produce, accomplish to have adventure
2. Develops confidence
3. Decentering: can consider more than one thing at a time, which leads to ability to
empathize, sympathize
4. Conservation: can recognize matter even if the form has changed; related to
permanence of mass and volume; knows that quantity remains the same even though appearance
differs.
 5. Reversibility: recognizes events even in their reverse for he can imagine a process in
reverse.
6. With concrete, logical thinking
7. Acquires use of reason and understanding of rules – allows greater use of language.
8. Names months and years, right and left, can tell time.

E. Play (COMPETITIVE, team, rule-governed)

1. Number of play activities decreases while the amount of time spent in one particular
activity increases.
2. Purposes of play:
a. To develop mental abilities, learn nature of competition
b. To learn to bargain, cooperate and compromise
c. To increase social activities
d. To increase motor abilities
e. To develop logical thinking/reasoning abilities
3. In the beginning of school years, boys and girls play together but gradually separate
into sex oriented type of activities (Normal Homosexual Period).
4. Team play; rules and rituals dominate play; individuality not tolerated by peers.
5. Types of Play/Games:
a. Quiet games: painting, collections, reading, watching TV, listening to
radio
b. Athletic activities: swimming, hiking, bicycling, basketball
c. 6-9 yrs : housekeeping toys, doll accessories,
needlework, collection and hobbies; physical games
tree-climbing, jump rope, bicycling
d. 9-12 years: handicrafts, science toys, magic sets,
chess, scrabble, model kits, video games,
radio/records; books and comics, mystery, adventure story; joke books
F. Morality
- Morality develops in the school- before age 9:
1. with strict superego
2. rule dominance - things are black or while; right or wrong
- After 9 years old, autonomous morality develops; recognizes differing points of view; may see
"gray areas.'

G. Concept on Death
6- 9 years Understands that death is final
Believes own death can be avoided Associates
death with aggression or violence Believes wishes
or unrelated actions can be responsible for death
9-12 years Understands death as the inevitable end
of life Begins to understand own mortality, expressed as
interest in afterlife or as fear of death
Expresses ideas about death gathered from 'parents and other
adults

Health Promotion during School Age

A. Nutrition
1. Calories: needs 2100 - 2400 calories per day
2. Breakfast is the most important meal.
3. More likely to eat junk foods and take zero-caloric foods (soft drinks).
4. To make the child take the needed calories: WELL-PLANNED SNACKS.
5. Tends to choose own foods, influenced by mass media, needs nutritional education -
nutritious snacks, cooking, meal planning
6. Displays good table manners.
B. Safety Concerns
1. Safety education is essential; accepts increasing responsibility for own safety.
2. Motor vehicle accidents - leading cause of injuries/accidents
a. Be role model as safe driver
b. Use of safety belts
c. Teach rules of pedestrians
d. No playing in streets or alleys
e. Practice bike safety
3. Provide supervision during sports activities.
4. Provide adult supervision during swimming and boating activities; provide teachings.
(Supervision and education are key elements in the prevention of accidents in this stage.)
5. Teach respect for fire and its dangers. 6. Teach on prevention of sexual abuse.
"Private parts" are those parts of the body covered by a bathing suit.
C. Dressing
- This is the right age to teach children the importance of caring for their own belongings.
- School age children have definite opinions about style or clothing, often based on the likes of
their friends rather than the preferences of their parents. A child who wears different clothing may
become the object of exclusion from a school club or group.
D. Sleep
- 10-12 hours of sleep a night
- prolonged telephone conversation ensues which may deprive them of adequate sleep at night.
E. Exercise
- This need not involve organized sports.
Common Health Problems
A. Anxiety Related to Beginning School
-The biggest task of the 1st year of formal school is learning to read.
- Urge parents to spend some time with the child after school or in
evening, family and does not feel pushed out by being sent to school;
or else, counseling may be done.
B. School Phobia
- Refers to fear of attending school
- Child may develop physical signs of illness.
- Causes:
a. anxiety of separation from home
b. teacher factor
c. particular school-related activities
- Parents should treat the situation matter-of-factly.
- This requires coordination among the school, school nurse and health care
provider who diagnose the problem.
C. Latchkey Children
- Refers to schoolchildren who are without adult supervision for a part of each
weekday.
The term alludes to the fact that they generally carry a key so they can let
Themselves into their homes after school.
- A major concern is that these children feel lonely and have an increased tendency
to have accidents, delinquent behavior and decreased school performance from
lack of homework supervision.
- For those children who feel safe, a short period of independence may actually
be beneficial because it encourages problem solving in self-care.
D. Stealing
- This happens @ around 7 years of age- they discover the importance of money.
- If stealing persists beyond 9 years of age - counseling may be required.
- Interventions:
1. Explore the cause of stealing.
2. Handle the situation without a great deal of emotion.
3. Importance of property rights must be emphasized.
4. Parents must set good examples.
E. Recreational Substance Use
- Illegal substances are available nowadays to children even during Grades V to VI.
- Commonly abused substances:
a. rugby (toluene)solvents
b. cigarettes
c. alcohol
d. marijuana
 ADOLESCENCE
- The period between 12-18 years old .this serves as a transition period between childhood and
adulthood.
- The whole period can be divided into:
a. Early Adolescence (12-14 yrs)
b. Middle Adolescence (Females: 13-16 yrs; Males: 13-17 yrs)
c. Late Adolescence (Females: 16-21 yrs; Males: 17-21 yrs)
- Period of "storm and stress."
- Second "rapid growth period."

Definition of Terms
1. Pubescence - the time span during which reproductive functions begin to mature; ends with the
attainment of full maturity or reproductive capacity and is characterized by:
a. rapid growth of the body
b. full genital development
c. sexual awareness
2. Puberty - period of full reproductive maturity.
a. Girls: Before, this period was believed to be heralded by the first
menses (Menarche). Studies, however, have shown that most
young girls are NOT FERTILE for about 1-2 yrs after menarche.
b. Boys: Puberty approaches at or near the first ejaculation. True
reproductive maturity is attained when viable sperms appear in the semen.
Pubescence and puberty deal with the physical/biological aspects of development of the young
boy or girl.
3. Adolescence - social and behavioral maturation from the beginning of pubescence to beyond
the time of reproductive maturity.

PHYSICAL GROWTH
- The major milestones of development in the adolescent period are the onset of puberty and the
cessation of body growth.
- Physiologic growth is rapid and the development of adult coordination is slow.
- Growth stops with closure of epiphyseal lines of long bones (16-18 yrs in females; 18-21 in
males).
A. Weight
- With pubertal "growth spurt."
- Females: 381bs mean weight gain (10-14 yrs)
- Males: 52 lbs mean weight gain (12-16 yrs)
B. Height
- With pubertal "growth spurt."
- Females: 20.5 cm mean height gain (10-14 yrs)
• 95% of mature height is achieved by the onset of menarche.
- Males: 27.5 cm mean height gain (12-16 yrs)
• 95(% of mature height is achieved by skeletal age of 15 yrs.
C. Body System
1. Skeletal System
- First, gain is mostly in weight, leading to stocky, slightly obese
appearance, then the thin appearance of late adolescence.
- Skeletal system grows faster than the muscles.
- These differences lead to:
a. lack of coordination
b. poor posture
- They appear long-legged and awkward because extremities
elongate first followed by trunk growth.
2. Cardiovascular and Respiratory System
- Heart and lungs increase in size more slowly than the rest of the
body - insufficient energy left for activity - CONSTANT
FATIGUE
(*Fatigue is also due to protein depletion, with protein being used up for body growth.)
- PR= 70 bpm
- RR= 20 cpm
- BP = 120170 mmHg (reaches adult levels @ late adolescence)
- BP in males> BP in females (due to large body mass in males)
3. Endocrine System
- Androgen stimulates sebaceous glands to extreme activity- ACNE.
-The formation of apocrine sweat glands (glands present in the
axilla and genital area) occurs shortly after puberty - strong body odor.
D. Dentition
- 2nd Molars: 12-13 yrs (Upper); 11-13 yrs (Lower)
- 3rd Molars (Wisdom Teeth) : 17-21 yrs but may erupt as early as 14-15 years
- Jaw reaches adult size toward the end of adolescence. As a result, adolescents whose 3rd
molars erupt before the lengthening of the jaw is complete may experience pain and may need
these molars extracted because they do not fit the jawline.
E. Secondary Sex Changes
(See Tanner's Sexual Maturity Ratings)

Psychosocial Patterns
A. Early Adolescence
1. Physical body changes can result to altered self-concept - FEAROF REJECTION.
2. Early and late developers may also have anxiety regarding fear of rejection.
3. May have mood swings.
4. With fantasy and daydreaming
5. Needs consistent discipline LIMIT BEHAVIOR
B. Middle Adolescence
1. Emancipated from parents (except financially)
2. Identifies own values
3. Finds increasing interest in heterosexual relationship; may find a mate or form "love"
relationship
4. With peer group
- One of the strongest motivating forces of behavior
- Finds importance to be a part of a group and be like everyone else in the group
conforms to values/fads of the group.
- Clique formation ("Barkada")- may be determined by race social class, special
interest.
C. Late Adolescence
1. Physically and financially independent from parents
2. Finds identity
3. Finds a mate
4. Develops morality
5. Increasing social and moral interest participates in society 6. Completes physical and
emotional maturity
D. Adolescence and Independence
1. By 15-16 yrs, adolescents feel they should be treated as adults.
2. Ambivalence: adolescent wants freedom but is not happy with corresponding
responsibilities that come with it.
3. Parental ambivalence is also present; they try to give the adolescent freedom but
continue to offer constructive guidance and enforce discipline.
Emotional Development
A. Sense of Identity
- Deciding who they are and what kind of person they will be.
- Four (4) main areas of concern to establish identity:
a. accepting changed body image
b. establishing a value system
c. making a career decision (may wait until 2ndYr College)
d. being emancipated from parents
- Some develop delinquent behavior - better to be socially unacceptable than to be nobody at all.
B. Sense of Intimacy
- Starts toward the end of adolescence and continues into early adulthood.
- The ability to form intimate relationships is strongly correlated with a sense of trust. Infants who
are unable to from a sense of trust may be unable to relate to others on a deep enough level to
form lasting and close relationships as adults
- They need to be helped to differentiate between sound relationships and those that are based
only on sexual attraction. .
- It is important for parents to keep the lines of communication open on the subject of sexuality.
 They should be taught to have a monogamous relationship and use contraceptives (e.g.
condom, pills) to prevent teenage pregnancy and sexually transmitted diseases.
- Intimacy involves:
a. developing sense of compassion or concern for other persons
b. discerning when words will hurt
c. determining when companion us unhappy and needs encouragement d. knowing when
a friend needs support (EMPATHY)

C. Socialization
12 year§ *full of "self-doubt"

13 years *loud and boisterous particularly when they

want to attract an opposite sex nearby
*start to "fall in love" (a painful kind of love; they, have too
little experience with life, too limited frame of reference to
know how to offer deep commitment)

14 years * quieter and more introspective

*used to their changing bodies; have more
confidence in themselves; feel more self:' esteem
*"Idol worship"(film star, rock star,
writer, scientist, doctor or athlete) starts

15 years *fall in love 5-6 times a year (attraction is

physical rather than the inner qualities)

16 years *"Sweet Sixteen" phenomenon *both sexes trust their bodies 17

years
*They leave childish behavior they used in early adolescence
(shoving and punching to get attention of the opposite sex)

Cognitive Development/Skills
- Formal Operations: child is capable of:
a. abstract thinking
b. scientific reasoning and formal logic
c. views problems comprehensively
d. increasing intellectual abilities, .
e. learning through intuition, inference and surmise rather than
imitation and repetition
f. making a hypothesis
Play
Girls social functions
romantic TV shows
reading romance books cooking, sewing
art and poetry
outings, movies
daydreaming
lengthy telephone conversations
Boys group activities predominate (e.g. drinking sessions)
sports
mechanical and electrical devices
part-time employment
outings, movies, parties

Health Promotion during Adolescence

A. Nutrition
- 2,200 calories in girls; 2,700 in boys
- Appetite increases with rapid growth.
*Inadequate diet results to retarded growth and delay in sexual maturity.
- Increased need for CHON, Ca++, Fe++, Zn++ for sexual maturation;
WATER is the most important element in his diet and in the diet of all age groups.
- Sports activities increase nutritional requirements.
- Eating habits are influenced by peer group:
a. junk foods
b. overeating and decreased activity OBESITY
c. fad diets and false dieting ANOREXIA NERVOSA and BULIMIA
B. Dress and Hygiene
- Capable of "self-care"
- Overly conscientious about appearance and personal hygiene
- Money is usually spent for clothing.
C. Care of the Teeth
- Individuals with braces must be extremely conscientious in tooth brushing to prevent plaque
buildup on tooth surfaces.
D. Sleep
- Need an average of 8 hrs sleep
- "Growth spurts" happen during sleep CHON synthesis and release of
somatotropic hormone happen when a person sleeps.
E. Exercise
- Needed to maintain muscle tone and to provide an outlet for tension.
F. Safety Measures
1. Accidents are the leading cause of death: motor vehicular accidents and sports injuries.
 2. Drugs and alcohol become serious problems in this stage.
3. Suicide may also be a cause of death.
4. Counsel against swimming alone and other risky behaviors.
Common Health Problems of the Adolescent
A. Hypertension
- Causative factors:
1. obesity
2. black race
3. diet high in salt and fat
4. family history of HPN
- BP should be taken routinely in children over 3 yrs of age.
B. Poor Posture
- Detect difference between normal posture and the beginning of scoliosis.
C. Fatigue
- Diet, sleep patterns and activity schedules must be assessed.
- May be a sign of boredom.
- RIO Anemia or other related illnesses
D. Menstrual Irregularities
- Check ups with an OB
-Gynecologist should be done if irregularities persist.
E. Acne ("Pimples")
- A common skin disorder which is a self-limiting inflammatory disease that
involves the sebaceous glands that empty into hair shafts (pilosebaceous unit).
- More common in boys than girls.
- Peak ages:
14-17 years (females)
16-19 years (males)
- Caused by abnormal keratinization, obstruction of ducts and trapping of sebum.
- Proprionibacterium acnes (a bacterium) cause papular lesions to appear.
- Fatty acids from triglycerides causes the dermal inflammation.
- Locations: face, neck, back, upper arms and chest
- Categories:
a. Mild - comedones
b. Moderate - papules and pustules
c. Severe - cysts
- Causes of flare-ups:
a. humidity
b. emotional stress
c. menstrual periods
d. greasy hair creams/make-ups
e. lack of sleep or irregular sleep patterns
 -No relationship to food intake (e.g., peanuts,. chocolates or fatty foods) or dirt (Wash face only 2-3x a day).
- Treatment goals:
a. decrease sebum production
b. prevent comedone formation
c. control bacterial proliferation
F. Substance Abuse
- Use of chemicals to improve mental state or induce euphoria.
- Substances commonly abused:
a. cigarettes
b. alcohol
c. anabolic steroids
d. marijuana
e. amphetamines
f. cocaine
g. hallucinogens
h. opiates
- Results:
a. school failure
b. poor reasoning ability
c. decreased school attendance
d. frequent mood swings
e. deteriorating physical appearance
f. recent change in peer group
g. expressed negative perceptions of parents h. delinquent behaviors (crimes)
G. Suicide
- A deliberate self-injury with the intent to end one's life.
- More frequent in males than females (Ratio 8:1).
- Ranks as 3rd cause of mortality among adolescents.
- Cause: LOSS OF A LOVED OBJECT
- Danger signs of suicide:
a. giving away prized possessions
b. organ donation questions
c. sudden, unexplained elevations of mood
d. accident proneness, carelessness, death wishes
e. statement such as, "This is the last time you'll see me."
f. decreased verbal communication
g. withdrawal from peer activities or previously enjoyed events
h. previous attempt at suicide
i. preference of art, music and literature with themes of death
j. recent increase in interpersonal conflict with significant others
k. running away from home
 l. inquiry about hereafter
m. asking for information about suicide prevention and intervention n. almost any sustained deviation from the
normal pattern of behavior.
G. Running Away
- This is usually preceded by an argument with parents that is often the last straw after a number of long-term
disagreements.
- They are usually "throw-aways" or have been rejected by families.
- Other reasons:
a. loneliness
b.pregnancy
c. problems with friends, school and police
d. incest or parental abuse
- School history usually reveals frequent truancy, failing grades, possible deluge use, running away behavior by friends.

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