Infants
Proportional changes * The infant’s posterior fontanel closes by 6 to 8 weeks of age. * The infant’s anterior fontanel closes by 12 to 18 months of age * Weight – Infants gain approximately 150 to 210 g (about 5 to 7 oz) per week the first 6 months of life. Birth weight is at least doubled by the age of 6 months, and tripled by the age of 12 months. * Height – Infants grow approximately 2.5 cm (1 in) per month the first 6 months of life. Growth occurs in spurts after the age of 6 months, and the birth length increases by 50% by the age of 12 months. * Head circumference – The circumference of infants’ heads increases approximately 1.5 cm (0.6 in) * per month for the first 6 months of life, and then approximately 0.5 cm (0.2 in) between 6 and 12 months of age.

Maturation of Systems * The respiratory rate slows somewhat and is relatively stable * The heart slows and the rhythm is soften sinus dysrhythmia * Systolic pressure rises during first 2 months and diastolic pressure rises first 3 months * The liver is the most immature of all the GI throughout infancy * Thermoregulation becomes more efficient. * A shift in total body fluid occurs

Nutrition * Feeding alternatives * Breastfeeding provides a complete diet for infants during the first 6 months. * Iron-fortified formula is an acceptable alternative to breast milk. Cow’s milk is not recommended. * It is recommended to begin vitamin D supplements within the first few days of life. * Iron supplements are recommended for infants who are being exclusively breastfed after the age of 4 months. * Alternative sources of fluids, such as juice or water, are not needed during the first 4 months of life * After the age of 6 months, 100% fruit juice should be limited to 4 to 6 oz. per day. * Solids are introduced around 4 to 6 months of age * Indicators for readiness include interest in solid foods, voluntary control of the head and trunk, and disappearance of the extrusion reflex. * Iron-fortified cereal is typically introduced first due to its high iron content. * New foods should be introduced one at a time, over a 4- to 7-day period, to observe for signs of allergy or intolerance, which may include fussiness, rash, vomiting, diarrhea, and constipation. * Vegetables or fruits are started first between 6 and 8 months of age. After both have been introduced, meats may be added. * Citrus fruits, meat, and eggs are not started until after 6 months of age. * Breast milk/formula should be decreased as intake of solid foods increases, but should remain the primary source of nutrition through the first year. * Table foods that are cooked, chopped, and unseasoned are appropriate by 9months of age. * Appropriate finger foods include ripe bananas; toast strips; graham crackers; cheese cubes, noodles; and peeled chunks of apples, pears, or peaches.

Dental Health * Six to eight teeth should erupt in infants’ mouths by the end of the first year of age. The first teeth typically erupt between the ages of 6 and 10 months * Teething pain can be eased using cold teething rings and over-the-counter teething gels.
Acetaminophen (Tylenol) and/or ibuprofen (Advil) are appropriate if irritability interferes with sleeping and feeding, but should not be used for more than 3 days. Clean infants’ teeth using cool, wet washcloths. * Bottles should not be given to infants when they are falling asleep because prolonged exposure to milk or juice can cause early childhood caries.

Language development * Crying is the first form of verbal communication. * Vocalizes with cooing noises. * Responds to noises. * Turns head to the sound of a rattle. * Laughs and squeals. * Pronounces single-syllable words. * Begins speaking two-word phrases and progresses to speaking three-word phrases. * Says three to five words and comprehends “no” by the age of 1 year

Social development * Social development is initially influenced by infants’ reflexive behaviors and includes attachment, separation, recognition/anxiety, and stranger fear. * Attachment is seen when infants begin to bond with their parents. This development is seen within the first month, but it actually begins before birth. The process is enhanced when infants and parents are in good health, have positive feeding experiences, and receive adequate rest. * Separation-individuation occurs during the first year of life as infants first distinguish themselves and their primary caregiver as separate individuals, and then develop object permanence. * Separation anxiety begins around 4 to 8 months of age. Infants will protest when separated from parents, which can cause considerable anxiety for parents. * Stranger fear becomes evident between 6 and 8 months of age, when infants are less likely to accept strangers. * Reactive attachment disorder results from maladaptive or absent attachment between the * infant and primary caregiver, and continues through childhood and adulthood

Sleep and Activity * Activity * Play should provide interpersonal contact and educational stimulation. * Infants have short attention spans and will not interact with other children during play (solitary play). * Rattles, teething toys, nesting toys * Playing pat-a-cake, playing with balls, reading a book * Mirrors * Brightly colored toys * Playing with blocks

Injury prevention and safety promotion * Aspiration * Avoid small objects. * Provide age-appropriate toys. * Check clothing for hazards such as loose buttons * Poisoning * Keep toxins and plants out of reach. * Place safety locks on cabinets where cleaners/chemicals are stored. * Use a carbon monoxide detector in the home. * Keep medications in childproof containers and out of reach. * Drowning * Do not leave unattended around any water source. * Secure fencing around swimming pool. * Keep bathroom door closed * Suffocation * Avoid plastic bags. * Ensure crib mattress fits snugly. * Remove crib mobiles by 4 to 5 months of age. * Keep pillows out of the crib. * Back to sleep * Infant-only and convertible infant-toddler car seats are available. * Infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height recommended by the manufacturer. * Safest area for infants and children is the backseat of the car. * Do not place rear-facing car seats in the front seat of vehicles with passenger airbags

AGE | GROSS MOTOR SKILLS | FINE MOTOR SKILLS | 1 month | Demonstrates head lag | Has a grasp reflex | 2 months | Lifts head off mattress when prone | Holds hands in an open position | 3 months | Raises head and shoulders off mattress when proneOnly slight head lag | No longer has a grasp reflexKeeps hands loosely open | 4 months | Rolls from back to side | Places objects in mouth | 5 months | Rolls from front to back | Uses palmer grasp dominantly | 6 months | Rolls from back to front | Holds bottle | 7 months | Bears full weight on feet | Moves objects from hand to hand | 8 months | Sits unsupported | Begins using pincer grasp | 9 months | Pulls to a standing positionCreeps on hands and knees instead | Has a crude pincer grasp | 10 months | Changes from a prone to a sitting position | Grasps rattle by its handle | 11 months | Walks while holding onto something | Places objects into a container Neat pincer grasp | 12 months | Sits down from a standing position without assistance | Tries to build a two-block tower without success |

Toddlers
Proportional changes * Anterior fontanels close by 18 months of age. * Weight – At 30 months of age, toddlers should weigh four times their birth weights. * Height – Toddlers grow about 7.5 cm (3 in) per year. * Head circumference and chest circumference are usually equal by 1 to 2 years of age

Nutrition * Children may establish lifetime eating habits during early childhood. * Toddlers begin developing taste preferences, and are generally picky eaters who repeatedly request their favorite foods. * Physiologic anorexia occurs, resulting in toddlers becoming fussy eaters because of a decreased appetite. * Toddlers should consume 24 to 30 oz of milk per day, and may switch from drinking whole milk to drinking low-fat milk after 2 years of age. * Juice consumption should be limited to 4 to 6 oz. per day. * Trans fatty acids and saturated fats should be avoided. * Diet should include 1 cup of fruit daily. * Food serving size should be 1 tbsp. for each year of age, or ¼ to 1/3 of an adult portion. * Toddlers generally prefer finger foods because of increasing autonomy. * Regular meal times and nutritious snacks best meet nutrient needs. * Snacks or desserts that are high in sugar, fat, or sodium should be avoided. * Foods that are potential choking hazards (nuts, grapes, hot dogs, peanut butter, raw carrots, tough meats, popcorn) should be avoided. * Adult supervision should always be provided during snack and mealtimes. * Foods should be cut into small, bite-size pieces to make them easier to swallow and to prevent choking * Toddlers should not be allowed to engage in drinking or eating during play activities or while lying down. * Parents should follow the U.S. Department of Agriculture’s guidelines (www.choosemyplate.gov).

Dental Health * Children should have an established dental home by the age of 1 year. * Flossing and brushing should be performed by the adult caregiver, and is the best method of removing plaque. * Brushing should occur after meals and at bedtime. Nothing to eat or drink, except water, is given to the child after the bedtime cleaning. * Fluoride is supplemented for children living in areas without adequate levels in drinking water. * Early childhood caries is a form a tooth decay that develops in toddlers, and is more common in children who are put to bed with a bottle of juice or milk. * Consumption of cariogenic foods should be eliminated if possible. If not, the frequency of consumption should be limited

Sleep and Activity * Sleep * Toddlers typically average 11 to 12 hours of sleep per day, including one nap. * Naps often are eliminated in older toddlerhood. * Resistance to bedtime and expression of fears are common in this age group. * Maintaining a regular bedtime and bedtime routines are helpful to promote sleep. * Activity * Solitary play evolves into parallel play, in which toddlers observe other children and then may engage in activities nearby. * Filling and emptying containers * Playing with blocks * Looking at books * Push-pull toys * Tossing balls * Finger paints * Large-piece puzzles * Thick crayons

Language development * Language increases to about 300 words by the age of 2 years. * 1 year – use one-word sentences, or holophrases * 2 years – use multiword sentences by combining two to three words * 3 years – combine several words to create simple sentences using grammatical rules

Injury prevention and safety promotion * Small objects (grapes, coins, candy) that can become lodged in the throat should be avoided. * Toys that have small parts should be kept out of reach. * Age-appropriate toys should be provided. * Clothing should be checked for safety hazards (loose buttons). * Balloons should be kept away from toddlers. * Parents should know emergency procedures for choking

AGE | GROSS MOTOR SKILLS | FINE MOTOR SKILLS | 15 months | Walks without help Creeps up the stairs | Uses a cup wellBuilds a tower of two blocks | 18 months | Assumes a standing positionThrows a ball overhand Jumps up and down with both feet | Manages a spoon without rotationTurns pages in a book, two or three at a time | 2 years | Walks up and down stairs by placing both feet on each step | Builds a tower of six or seven blocks | 2.5 years | Jumps across the floor using both feet and off a chair or stepStands on one foot momentarily | Has good hand-finger coordinationDraws circles |

Preschoolers
Proportional changes * Weight – Preschoolers should gain about 2 to 3 kg (4.4 to 6.6 lb) per year. * Height – Preschoolers should grow about 6.5 to 9 cm (2.6 to 3.5 in) per year. * Preschoolers’ bodies evolve away from the characteristically unsteady wide stances and protruding abdomens of toddlers, into a more graceful, erect, and sturdy physicality.

Nutrition * Preschoolers consume about half the amount of energy that adults do (1,800 kcal). * Picky eating may remain a behavior in preschoolers, but often by 5 years of age they become more willing to sample different foods. * Preschoolers need 13 to 19 g/day of protein in addition to adequate calcium, iron, folate, and vitamins A and C. * Saturated fats should be less than 10% of preschoolers’ total caloric intake, and total fat over several days should be 20% to 30% of total caloric intake

Dental Health * Eruption of primary teeth is finalized by the beginning of the preschool years. * Parents need to assist and supervise brushing and flossing to ensure performed appropriately and prevent dental caries. * Trauma to teeth is common in preschool-age children and should be immediately assessed by a dentist.

Sleep and Activity * On average, preschoolers need about 12 hours of sleep per day. Some still require a daytime nap. * Sleep disturbances frequently occur during early childhood, and problems range from difficulty going to bed to sleep terrors certain interventions can help * Keep a consistent bedtime routine. * Use a night-light. * Reassure preschoolers who are frightened, but avoid allowing preschoolers to sleep with their parents

Social development * Preschoolers generally do not exhibit stranger anxiety and have less separation anxiety. * Prolonged separation, such as during hospitalization, can provoke anxiety * Favorite toys and appropriate play should be used to help ease preschoolers’ fears * Pretend play is healthy and allows preschoolers to determine the difference between reality and fantasy.

Language development * The vocabulary of preschoolers increases to more than 2,100 words by the end of the fifth year. * Preschoolers speak in sentences of three to four words at the ages of 3 and 4 years, and four to five words at the age of 4 to 5 years. * This age group enjoys talking, and language becomes their primary method of communication

AGE | GROSS MOTOR SKILLS | FINE MOTOR SKILLS | 3 years old | Rides a tricycle Jumps off bottom stepStands on one foot for afew seconds | Improvement should show in copying figures on paper and dressing independently | 4 years old | Skips and hops on one footThrows ball overhead | | 5 year old | Jumps ropeWalks backward with heel to toeThrows and catches a ball with ease | |

School-Age children
Proportional changes * Weight – School-age children will gain about 2 to 3 kg (4.4 to 6.6 lb.) per year. * Height – School-age children will grow about 5 cm (2 inches) per year * Prepubescence * Preadolescence is typically when prepubescence occurs. * Onset of physiologic changes begins around the age of 9 years, particularly in girls. * Rapid growth in height and weight occurs. * Differences in the rate of growth and maturation between boys and girls becomes apparent. * Visible sexual maturation is minimal in boys during preadolescence

Maturation of System * Bladder capacity differs, but remains greater in girls than boys. * Immune system improves. * Bones continue to ossify

Nutrition * By the end of the school-age years, children should eat adult portions of food. They need quality nutritious snacks * Obesity is an increasing concern of this age group that predisposes children to low self-esteem, diabetes, heart disease, and high blood pressure. * Avoid using food as a reward. * Emphasize physical activity. * Ensure that a balanced diet is consumed by following the U.S. Department of Agriculture’s healthy diet recommendations (www.choosemyplate.gov). * Teach children to make healthy food selections for meals and snacks. * Avoid eating fast-food frequently. * Avoid skipping meals. * Model healthy behaviors

Sleep and Activity * Competitive and cooperative play is predominant * Play simple board and number games. * Play hopscotch * Jump rope. * Collect rocks, stamps, cards, coins, or stuffed animals. * Ride bicycles. * Build simple models. * Join organized sports (for skill building) * Make crafts and build models. * Collect things/engage in hobbies and solve jigsaw puzzles, play board and card games. * Join organized competitive sports.

Dental health * Permanent teeth erupt.

Injury prevention and safety promotion * Stand back from curb while waiting to cross the street. * Before crossing the street look left, then right, then left again * Walk on the left, facing traffic, when there are no sidewalks. * At night, wear light-colored clothing with fluorescent materials attached.

Social development * Peer groups play an important part in social development. Peer pressure begins to take effect. * Clubs and best friends are popular. * Bullying actions are intended to cause harm or to control someone, and are sometimes attributed to poor relationships with peers and difficulty identifying with a group. * Children prefer the company of same-gender companions, but begin developing an interest in the opposite sex toward the end of the school-age years. * Most relationships come from school associations. * Conformity becomes evident.

Adolescents
Proportional changes * The final 20% to 25% of height is achieved during puberty * Girls stop growing at about 2 to 2.5 years after the onset of menarche. They grow 5 to 20 cm (2 to 8 in) and gain 7 to 25 kg (15.5 to 55 lb.). * Boys stop growing at around 18 to 20 years of age. They grow 10 to 30 cm (4 to 12 inches) and gain 7 to 30 kg (15.5 to 66 lb.)

Maturation of system * Girls (correct order) * Breast development * Pubic hair growth (some girls experience hair growth before breast development) * Axillary hair growth * Menstruation * Boys (correct order) * Testicular enlargement * Pubic hair growth * Facial hair growth * Vocal changes

Nutrition * Rapid growth and high metabolism require increases in quality nutrients, and make adolescents unable to tolerate caloric restrictions. * During times of rapid growth, additional calcium, iron, and zinc are needed. * Inadequate intake of folic acid, vitamin B vitamin A, iron, calcium, and zinc is common. * Both overeating and undereating present special challenges during the adolescent years. * Yearly assessments of height, weight, and BMI for age are needed in order to identify nutritional issues and intervene early. * Advise parents to * Avoid using food as rewards and emphasize physical activity * Ensure that a balanced diet is consumed by following the U.S. Department of Agriculture’s healthy diet recommendations (www.choosemyplate.gov). * Encourage adolescents to make healthy food selections for meals and snacks

Dental Health * Corrective appliances are most common with this age group. * Brush after meals and snacks, and at bedtime. * Floss daily and have regular checkups * If necessary, have regular fluoride treatments

Injury Prevention and Safety promotion * Motor-vehicle injuries * Encourage attendance at drivers’ education courses. Emphasize the need for adherence to seat belt use * Insist on helmet use with bicycles, motorcycles, skateboards, roller skates, and snowboards. * Discourage use of cell phones while driving and enforce laws regarding use. * Teach the dangers of combining substance abuse with driving. * Role model desired behavior

Sleep and Activity * Sleep * Sleep habits change with puberty due to increased metabolism and rapid growth. * Adolescents tend to stay up late, sleep in later in the morning, and sleep more than during the school-age years. * During periods of active growth, the need for sleep increases. * Activity * Nonviolent video games * Nonviolent music * Sports * Caring for a pet * Career-training programs * Reading * Social events (going to movies, school dances)

Social Development * Peer relationships develop. These relationships act as a support system for adolescents. * Best-friend relationships are more stable and longer-lasting than they were in previous years. * Parent-child relationships change to allow a greater sense of independence.

| Infant Birth to 1 year | Toddlers 1 to 3 Years | Preschoolers 3 to 6 years | School age children6 to 12 years | Adolescent 12 to 18 years | Freud (Psychosexual development) | Oral * The major source of pleasure seeking is centered on oral activities such as sucking, chewing, biting, and vocalizing, children may prefer one of these over the other, and the preferred method of gratification can provide some indication of the personality they develop. | Anal * Interest during the second year of life centers in the anal region as sphincter muscles develop and the children are able to withhold or expel fecal material at will. At this stage the climate surrounding toilet training can have lasting effect on the children’s personalities | Phallic * During this stage the genitalia become an interesting and sensitive area of the body. Children recognize the difference between sexes and become curious about the dissimilarities * Period of controversial issues of the Oedipus and Electra complexes, penis envy, and castration anxiety are centered. | Latency * Children elaborate on previously acquired traits and skills. Physical and psychic energy is channeled into acquisition of knowledge of vigorous play | Genital * Begins at puberty with the maturation of the reproductive system and production of sex hormones. The genital organs become the major source of sexual tensions and pleasures, but energies are also invested in forming friendships and preparing for marriage | Erikson(Psychosocial development) | Trust vs. Mistrust * Achieving this task is based on the quality of the caregiver-infant relationship and the care received * The infant begins to learn delayed gratification. * Trust is developed by meeting comfort, feeding, stimulation, and caring needs. * Mistrust develops if needs are inadequately or inconsistently met, or if needs are continuously metbefore being vocalized by the infant. | Autonomy vs. Shame and doubt * Independence is paramount for toddlers, who are attempting to do everything for themselves. * Toddlers often use negativism, or negative responses, as they begin to express their independence. * Ritualism, or maintaining routines and reliability, provides a sense of comfort for toddlers as they begin to explore the environment beyond those most familiar to them. | Initiative vs. guilt * Preschoolers become energetic learners, despite not having all of the physical abilities necessary to be successful at everything * Guilt may occur when preschoolers believe they have misbehaved or when they are unable to accomplish a task * Guiding preschoolers to attempt activities within their capabilities while setting limits is appropriate | industry vs. inferiority * A sense of industry is achieved through the development of skills and knowledge that allows the child to provide meaningful contributions to society * A sense of accomplishment is gained through the ability to cooperate and compete with others * Children should be challenged with tasks that need to be accomplished, and be allowed to work through individual differences in order to complete the tasks * Creating systems that reward successful mastery of skills and tasks can create a sense of inferiority in children unable to complete the tasks or acquire the skills * Children should be taught that not everyone will master every skill. | identity vs. role confusion * Adolescents develop a sense of personal identity, and come to view themselves as unique individuals * Group identity Adolescents become part of a peer group that greatly influences behavior | Piaget(Cognitive development) | Sensorimotor stage (birth to 24 months) * Progress from reflexive to simple repetitive to imitative activities. * Separation, object permanence, and mental representation are the three important tasks accomplished in this stage. * Separation – Infants learn to separate themselves from other objects in the environment * At 9 months of age an infant’s know an object still exist when it is out of view * Mental representation is the recognition of symbols | Sensorimotor stage(19 to 24 months) * The concept of object permanence becomes fully developed. * Toddlers have and demonstrate memories of events that relate to them * Domestic mimicry (playing house) is evident. * Preoperational thought does not allow for toddlers to understand other viewpoints, but it does allow them to symbolize objects and people to imitate previously seen activities | The preconceptual phase transitions to the phase of intuitive thought around the age of 4 years till 7 years * The preschooler moves from totally egocentric thoughts to social awareness and the ability to understand the viewpoints of others | Concrete operations * Transitions from perceptual to conceptual thinking * Masters the concept of conservation * Conservation of mass is understood first, followed by weight, and then volume * Learns to tell time and classifies more complex information * Able to see perspective of others and solve problem | formal operations * Able to think through more than two categories of variables concurrently * Capable of evaluating the quality of their own thinking and maintain attention for a longer period of time * Highly imaginative and idealistic * increasingly capable of using formal logic to make decisions * Think beyond current circumstances and understands how the reaction of an individual affect others | Kohlberg(Moral development) | | * Egocentric – Toddlers are unable to see things from the perspectives of others; they can only from their personal points of view * Punishment and obedience orientation begin with a sense that good behavior is rewarded and bad behavior is punished | * Early preschoolers continue in the good-bad orientation of the toddler years, and actions are taken based on whether or not it will result in a reward or punishment * Older preschoolers primarily take actions based on satisfying personal needs, yet are beginning to understand the concept of justice and fairness | Early school-age years * Do not understand the reasoning behind rules and expectations for behavior. * Believe what they think is wrong, and what others tell them is right. * Judgment is guided by rewards and punishment * Sometimes interpret accidents as punishmentLater school-age years * Able to judge the intentions of an act rather than just its consequences * Understand different points of view instead of just whether or not an act is right or wrong * Conceptualizes treating others as they like to be treated | * Solve moral dilemma using internalized moral principles * Question relevance of existing moral values to society and individuals. |

Kohlberg (Moral development) * Preconventional Level * Culturally oriented to the labels of good/bad and right and wrong. * Children integrate these terms of the physical or pleasurable consequences of their action * Conventional level * Children are concerned with conformity and loyalty. They value the maintenance of family, group, or national expectations regardless of consequences * Post conventional, autonomous, or principle level * Individual has reached the cognitive stage of formal operations. Correct behavior tends to be defined in terms of general individual rights and standard that have been examined and agreed on by the entire society

Fowler (Spiritual Development) * Stage 0: Undifferentiated * Children have no concept of right or wrong, no beliefs and no convections to guide their behaviors * Stage 1: Intuitive-projective * The time of imitating the behavior of others * Children imitate the religious gestures and behaviors of others without comprehending any meaning of or significance to the activities * Stage 2: Mythical- literal * Most children have a strong interest in religion * Good behavior is rewarded and bad behavior is punished * They accept the existence of a deity and petitions to an omnipotent being are important and expected to be answered * Stage 3: Synthetic-convention * Children become increasingly aware of spiritual disappointments. * They recognize that prayers are not always answered * They begin to reason and question parents religious standards * Stage 4: Individuating-reflexive * Adolescents become more skeptical and begin to compare the religion of their parents against others

Immunization

Age | Vaccine | Birth | Hepatitis B | 2 months | DTAP, RV, IPV, Hib, PCV, Hep B | 4 moths | DTAP, RV, IPV, Hib, PCV | 6 months | DTAP, IPV(6 to 18 months), PCV, and Hep B (6 to 12 months), RV, Hib | 6 to 12 months | Seasonal influenza vaccine (TIV) | 12 to 15 months | IPV, (3rd b/w 6 to 18 months) | 12 to 23 months | Hepatitis A, (Given in two doses at least 6 months apart) | 15 to 18 months | DTaP | 12 to 36 months | TIV, (LAIV) by nasal spray (at 2 years of age) | 4 to 6 years | (DTaP), MMR, Varicella, IPV | 3 to 6 years | TIV, OR LAIV by nasal spray | 6 years | DTaP, MMR Varicella, IPV (If not given between 4 and 5 years of age) | 11 to 12 years | Tdap, HPV2 or HPV4in three doses for females, HPV4 for males, and MCV4 | 13 to 18 years | catch-up doses of any recommended immunizations not received at 11 to 12 years of age | 16 to 18 years | MCV4, (recommended if first dose was received b/w the ages of 13 and 15 years. A booster dose is not needed if the first dose is received at 16 or older |

Key: DTAP- Diphtheria and tetanus toxoids and pertussis RV- Rotavirus vaccine IPV- Inactivated poliovirus Hib- Haemophilus influenza type B PCV- pneumococcal vaccine TIV- Trivalent inactivated influenza LAIV- Live attenuated influenza vaccine MMR- measles, mumps, and rubella Tdap- tetanus and diphtheria toxoids and pertussis vaccine HPV- Human papillomavirus vaccine MCV4 –Meningoocccal