CARE OF MOTHER, CHILD AT RISK | NCM 109

CHAPTER 29: NURSING CARE OF A FAMILY WITH AN INFANT

PHYSICAL GROWTH BODY SYSTEMS

WEIGHT • Cardiovascular system
• Birth weight o Heart rate
o Double by 4 to 6 months ▪ Slows from 110 to 160 beats per minute to 100 to 120
o Triple by 1 year beats per minute by the end of the first year.
• First 6 months of infants o The heart continues to occupy a little over half the width
o Average weight gain = 2 lb per month of the chest.
• Second 6 months o Pulse rate may slow with inhalation (sinus arrhythmia),
o Weight gain is approximately 1 lb per month. but does not become marked until preschool age.
• Average weight of 1-year-olds o The heart is becoming more efficient
o Males = 10 kg (22 1b) ▪ Decreasing pulse rate
o Femals = 9.5 kg (21 lb) ▪ Slightly elevated blood pressure (from an average of
80/40 to 100/60 mm Hg).
LENGTH o Prone to develop physiologic anemia at 2 to 3 months.
• An infant increases in length during the 1st year by 50%, or o Hemoglobin in an infant
grows from the average birth length of 20 in. to about 30 in. ▪ Totally converted from fetal to adult hemoglobin at 5
(50.8 to 76.2 cm). to 6 months of age.
• Infant growth during the early months o Decrease in serum iron levels at 6 to 9 months.
o Most apparent in the trunk • Respiratory system
• Infant growth during the second half of the 1st year o Respiratory rate of an infant
o Becomes more apparent as lengthening of the legs occurs. ▪ Slows from 30 to 60 breaths per minute to 20 to 30
• End of the 1st year breaths per minute by the end of the first year.
o The child's legs may still appear disproportionately short, o Upper respiratory infections occur more often and tend to
however, and perhaps bowed. be more severe than in adults.
• Measure infants lying supine on a measuring board even if they • Gastrointestinal system
are beginning to be able to stand for accuracy. o Gastrointestinal tract
HEAD CIRCUMFERENCE ▪ Immature in its ability to digest food and
• End of the 1st year mechanically move it along at birth.
o The brain already reaches two-thirds of its adult size. ▪ They mature gradually during the infant year.
• Head circumference increases rapidly during the infant period ▪ Amylase
to reflect this rapid brain growth. - For digestion of complex carbohydrates
• Some infants' heads appear asymmetric until the 2nd half of the - Decreased until approx. the 3rd month
first year, especially if they are always placed on their back to ▪ Lipase
sleep (as recommended), causing the skull bones to flatten in - For digestion of saturated fat
the back. - Decreased during entire 1st year
o Place infant on their back for sleep but spend "tummy • Liver of an infant
time" daily with infant placed in a prone position to o Immature
prevent this flattening. o Until age 3 or 4 months, an extrusion reflex (food placed
o This early head distortion will gradually correct itself as on an infant's tongue is thrust forward and out of the
the child sleeps less and spends more time with the head mouth) prevents some infants from eating effectively if
in an erect position. they are offered solid food this early (not recommended).
o Persistence of asymmetry = not receiving enough o Newborns can drink from a cup as long as a parent
stimulation. controls the fluid flow.
o An infant can independently drink from a cup by age 8 or
BODY PROPORTION
10 months.
• By the end of the infant period, the lower jaw is definitely
• Kidneys of an infant
prominent and remains that way throughout life.
o Immature and not as efficient as eliminating body wastes
• Chest circumference
as in an adult.
o Generally, less than that of the head at birth by about 2
• Endocrine system
cm.
o Particularly immature in response to pituitary stimulation,
o It is even with the head circumference in some infants as
such as adrenocorticotropic hormone, or insulin
early as 6 months and in most by 12 months.
production from the pancreas.
o The abdomen remains protuberant until the child has
▪ Without these hormones functioning effectively, an
been walking well into the toddler period.
infant may not be able to respond to stress as
• Cervical, thoracic, and lumbar vertebral curves
effectively as an adult may.
o Develop as infants hold up their head, sit, and walk.
• Immune system of an infant
• Lengthening of lower extremities during the last 6 months of
o Functional at least 2 months of age;
infancy
o Can actively produce both immunoglobulin (Ig)G and IgM
o Readies the child for walking and often is the final growth
antibodies by 1 year.
that changes the appearance from "baby-like" to "toddler-
o The levels of other Igs (IgA, IgE, and IgD) are not plentiful
like."
until preschool age.
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 CARE OF MOTHER, CHILD AT RISK | NCM 109
CHAPTER 29: NURSING CARE OF A FAMILY WITH AN INFANT

• Ability to adjust to cold • 3 months – lift and maintain their head well above the plane
o Matures by age 6 months. of the rest of the body
▪ By this age, an infant can shiver in response to cold • A Landau reflex is a new reflex that develops at 3 months.
(which increases muscle activity and provides o When held in ventral suspension, the infant's head, legs,
warmth) and has developed additional adipose and spine extend.
tissue to serve as insulation. o When the head is depressed, the hips, knees, and elbows
o The amount of brown fat, which protected the newborn flex.
from cold, decreases during the first year as subcutaneous o This continues to be present in most infants during the 2nd
fat increases. 6 months of life, but then it becomes increasingly difficult
• Extracellular fluid to demonstrate.
o 35% of an infant's body weight (20% in adults) • 6 to 9 months – demonstrates a parachute reaction
• Intracellular fluid o Means that when infants are suddenly lowered toward an
o 40% by the end of the first year (40% in adults) examining table, the arms extend as if to protect
o This proportional difference increases an infant's themselves from falling.
susceptibility to dehydration from illnesses, such as PRONE POSITION
diarrhea, because loss of extracellular fluid could result in • When lying on their stomach, newborns can turn their head to
loss of over a third of an infant's body fluid.
move it out of a position where breathing is impaired, but they
TEETH cannot hold their head raised for an extended time.
• The first baby tooth (typically, a central incisor) usually erupts • 1 month – lift their head and turn it easily to the side.
at age 6 months, followed by a new tooth monthly until all 20 o Keep their knees tucked under their abdomen
deciduous (baby) teeth have erupted by age 2 to 3 years. • 2 months – can raise their head and maintain the position, but
• However, teething patterns can vary greatly among children. they cannot raise their chest high enough to look around yet.
o Some newborns (about one in 2,000) may be born with o Their head is still held facing downward.
teeth (natal teeth) or have teeth erupt in the first 4 weeks • 3 months – lifts the head and shoulders well off the table and
of life (neonatal teeth). looks around when prone.
o The lower central incisors are the teeth most frequently o The pelvis is flat on the table, no longer elevated.
involved in this early growth. • 4 months – lift their chests off the bed and look around
▪ They may be membranous and may be reabsorbed actively, turning their head from side to side.
(supernumerary or extra teeth). o Able to turn from front to back.
▪ If they are loosely attached, they are usually removed o The first time, this tends to occur as an extension of lifting
before they loosen spontaneously and are aspirated the chest combined with a neck-righting reflex, which
by the infant. begins at this age.
• In most infants, natal or neonatal teeth are deciduous or are ▪ This reflex causes babies to lose their balance and roll
fixed firmly. sideways when lifting the head up.
o Should not be removed because no other teeth will grow • Most babies turn front to back first and then, 1 month later,
to replace them until the permanent teeth erupt at age 6 back to front.
or 7 years. o When taking a health history, ask which way a child
o Deciduous teeth are essential for allowing proper growth turned first.
of the dental arch. o Those with spasticity may turn first back to front.
MOTOR DEVELOPMENT • 5 months – rest weight on their forearms when prone.
• An average infant progresses through systematic motor o Can turn completely over, front to back and back to front.
growth during the first year, strongly reflecting the principles of • 6 months – raise their chests and the upper part of their
cephalocaudal (head to toe) and gross-to-fine motor abdomens off the table.
development. • 9 months – can creep from the prone position.
• Control proceeds from head to trunk to lower extremities in a o Creeping means the child has the abdomen off the floor
progressive, predictable sequence. and moves one hand and one leg and then the other hand
• To assess motor development, both gross motor development and leg, using the knees on the floor to move.
(ability to accomplish large body movements) and fine motor SITTING POSITION
development, measured by observing or testing prehensile • When the infant is placed on the back and then pulled to a
ability (ability to coordinate hand movements), are evaluated. sitting position, a newborn has extreme head lag
GROSS MOTOR DEVELOPMENT o This is present until about 1 month
VENTRAL SUSPENSION POSITION • In a sitting position, the back appears rounded and an infant
• Refers to an infant's appearance when held in midair on a demonstrates only momentary head control.
horizontal plane and supported by a hand under the abdomen • 2 months – can hold their head steady when sitting up,
• In this position, the newborn allows the head to hang down although their head does tend to bob forward and will still
with little effort at control. show head lag when pulled to a sitting position.
• 1 month – lift their head momentarily and then drop it again. • 4 months – no longer demonstrating head lag
• 2 months – hold their head in the same plane as the rest of • 5 months – straighten their back when held or propped in a
their body, a major advance in muscle control. sitting position.

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 CARE OF MOTHER, CHILD AT RISK | NCM 109
CHAPTER 29: NURSING CARE OF A FAMILY WITH AN INFANT

• 6 months – sit momentarily without support. • 8 months – random reaching and ineffective grasping
o They anticipate being picked up and reach up with their disappear as a result of advanced eye-hand coordination.
hands from this position. • 10 months – bring the thumb and first finger together in a
o Infants are capable of movement by sliding backward from pincer grasp
this position. o This enables children to pick up small objects
• 7 months – can sit alone but hands are held forward for o They use one finger to point at objects
balance. o They offer toys to people but then cannot release them
• 8 months – can sit securely without any additional support • 12 months – can hold a crayon well enough to draw a semi-
o Children with delayed cognitive or motor development straight line.
may not accomplish this step at this time. o They enjoy putting objects such as small blocks in
• 9 months – sit so steadily that they can lean forward and regain containers and taking them out again.
their balance. o They can hold a cup and spoon to feed themselves fairly
STANDING POSITION well (if they have been allowed to practice) and can take
off socks and push their hands into sleeves (again, if they
• 1 month – A newborn stepping reflex can still be demonstrated
have been allowed to practice).
o In a standing position, the infant's knees and hips flex
o They can offer toys and release them.
rather than support more than momentary weight
• 3 months – try to support part of their weight on their feet DEVELOPMENTAL MILESTONES
• 4 months – able to support their weight on their legs LANGUAGE DEVELOPMENT
o Stepping reflex has faded • 1 month – begin to make small, cooing sounds by the end of
• 5 months – tonic neck reflex should be extinguished, and Moro the first month
reflex should be fading • 2 months – can differentiate their cry
• 6 months – nearly support their full weight when in a standing • 3 months – in response to a nodding, smiling face or a friendly
position tone of voice, a 3-month-old infant will squeal with pleasure or
• 7 months – bounces with enjoyment in a standing position. laugh aloud
• 9 months – can stand holding onto a low table • 4 months – very talkative, and when spoken to, they start
• 10 months – pull themselves to a standing position by holding cooing, babbling, and gurgling, and definitely laugh aloud
onto the side of a playpen or a low table, but they cannot let • 5 months – says some simple vowel sounds (e.g., "goo-goo,"
themselves down again "gah-gah").
• 11 months – learns to "cruise" or move about the crib or room • 6 months – learn the art of imitating
by holding onto objects such as the crib rails, chairs, walls, and • 7 months – the amount of talking infants do increases and can
low tables imitate vowel sounds well (e.g., "oh-oh," "ah-ah," "00-00").
• 12 months – can stand alone at least momentarily • 9 months – usually speaks a first word: "da-da" or "ba-ba."
FINE MOTOR DEVELOPMENT • 10 months – masters another word such as "bye-bye" or "no."
• 1 month – still have a strong grasp reflex, so they hold their • 12 months – generally say an additional two words, and they
hands in fists so tightly that it is difficult to extend their fingers. use those two words with meaning.
• 2 months – hold an object for a few minutes before dropping PLAY
it. • 1 month – fix their eyes on an object, they are interested in
o The hands are held open, not closed in fists. watching a mobile over their crib or playpen.
• 3 months – reach for attractive objects in front of them. o Mobiles are best if they are black and white or brightly
o Their grasp is unpracticed so they usually miss them. colored and light enough in weight so they move when
• 4 months – bring their hands together and pull at their clothes. someone walks by.
o Thumb opposition (ability to bring the thumb and fingers o Mobiles should face down toward the infant, not toward
together) begins, but the motion is a scooping or raking the adult standing beside the crib.
one, not a picking-up one, and is not very accurate. o Musical mobiles provide extra stimulation.
o Palmar and plantar grasp reflexes have disappeared. • Hearing is a second sense that is a source of pleasure for
• 5 months – accept objects that are handed to them by children in early infancy.
grasping with the whole hand. o They stir and seem apprehensive at the sound of a
o They can reach and pick up objects without the object raucous rattle.
being offered and often play with their toes as objects. • 2 months – hold light, small rattles for a short period but then
• 6 months – grasping has advanced to a point where a child can drop them.
hold objects in both hands. • 3 months – handle small blocks or small rattles.
o Infants at this age will drop one toy when a second one is • 4 months – need a playpen or a sheet spread on the floor so
offered. they have an opportunity to exercise rolling over.
o They can hold a spoon and start to feed themselves (with • 5 months – ready for a variety of objects to handle, such as
much spilling). plastic rings, blocks, squeeze toys, clothes-pins, rattles, and
o The Moro, the palmar grasp, and the tonic neck reflexes plastic keys.
have completely faded. • 6 months – sit steadily enough to be ready for bathtub toys
• 7 months – transfer toys from one hand to the other. such as rubber ducks or plastic boats.
o They hold the first object when a second one is offered. o Because they are starting to teethe, most at this age enjoy
a teething ring to chew on.
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 CARE OF MOTHER, CHILD AT RISK | NCM 109
CHAPTER 29: NURSING CARE OF A FAMILY WITH AN INFANT

• 7 months – can transfer toys that are small enough to be • 12 months – easily locate sounds in any direction and turn
transferred easily and begin to be more interested in brightly toward them.
colored balls or toys that previously rolled out of reach. • 1st year – infants appear to enjoy soft, musical sounds or
• 8 months – sensitive to differences in texture and enjoy having cooing voices (Box 29.3); they are startled by harsh or loud
toys with different feels to them sounds.
• 9 months – needs the experience of creeping. TOUCH
o They begin to enjoy toys that go inside one another, such • Infants need to be touched so they can experience skin-to-skin
as a nest of blocks or rings of assorted sizes that fit on a contact.
center post. • Clothes should feel comfortable and soft rather than rough;
• 10 months – ready for peek-a-boo and will spend a long time diapers should be dry rather than wet.
playing the game with their hands or with a cloth over their • Teach caregivers to handle infants with assurance yet
head that they can easily reach and remove. gentleness.
o They can clap, so they are also ready to play patty-cake.
TASTE
• 11 months – have learned to cruise or walk by holding on to
low tables. • They have an acute sense of taste
o They turn away from or spitting out a taste they do not
• 12 months – enjoy putting things in and taking things out of
enjoy.
containers, and enjoy listening to someone recite nursery
• 6 months – when infants are introduced to solid food, urge
rhymes or play music.
caregivers to make mealtime a time for fostering trust as well
DEVELOPMENT OF SENSES as supplying nutrition
VISION SMELL
• 1 month – able to regard an object in the midline of their • Infants have a highly developed sense of smell within 1 or 2
vision (something directly in front of them) as soon as it is hours of birth.
brought in as close as about 18 in. (46 cm). • They respond to an irritating smell by turning their head away
o They follow the object a short distance if it moves, but
from it.
not across the midline yet.
• They appear to enjoy pleasant odors and learn early in life to
o They study or regard a human face with a fixed stare.
identify the familiar smell of breast milk.
• 2 months – focus well (from about age 6 weeks) and so are able
to follow moving objects with the eyes (although still not past EMOTIONAL DEVELOPMENT
the midline). • Socialization, or learning how to interact with others, is an
o The infant has achieved binocular vision or the ability to extensive phenomenon.
fuse two images into one • 1 month – can differentiate between faces and other objects
• 3 months – can follow an object across their midline. by studying a face or the picture of a face longer than other
o They typically hold their hands in front of their face and objects.
study their fingers for long periods of time. o They are calm and feed well for the person who has been
• 4 months – able to recognize familiar objects and eagerly their primary caregiver.
follow their caregivers' movements with their eyes. o When an interested person nods and smiles at a 6-week-
• 6 months – capable of organized depth perception. old infant, the infant smiles in return. This is a social smile
o This increases the accuracy of their reach for objects as and is a definite response to the interaction, not the faint,
they begin to perceive distances correctly. quick smile that younger infants, even newborns,
• 7 months – pat their own image in a mirror. demonstrate.
o Their depth perception has matured to the extent that • 3 months – demonstrate increased social awareness by readily
they can perform such tasks as transferring toys from hand smiling at the sight of a caregiver's face and laugh aloud at the
to hand. sight of a funny face.
• 10 months – looks under a towel or around a corner for a • 4 months – when a person who has been playing with and
concealed object (the beginning of object permanence, or an entertaining an infant leaves, the infant is likely to cry or show
awareness that an object out of sight still exists). that the interaction was enjoyable.
• 5 months – may show displeasure when an object is taken
HEARING
away from them.
• 1 month – this reaction (a newborn quiets momentarily at a • 6 months – increasingly aware of the difference between
distinctive sound such as a bell or a squeaky rubber toy) is even
people who regularly care for them and strangers.
more marked. o May begin to draw back from unfamiliar people.
• 2 months – hearing awareness becomes so acute infants will
• 7 months – begin to show obvious fear of strangers.
stop an activity at the sound of spoken words. o They may cry when taken from their parent, attempt to
• 3 months – turn their head to attempt to locate a sound. cling to the parent, and reach out to be taken back.
• 4 months – when infants hear a distinctive sound, they turn and • 8 months – Fear of strangers reaches its height during the
look in that direction. eighth month, so much so that this phenomenon is often
• 5 months – demonstrate they can localize sounds downward termed eighth-month anxiety, or stranger anxiety.
and to the side, by turning their head and looking down. o An infant at the height of this phase will not go willingly
• 6 months – able to locate sounds made above them. from a parent's arms to a nurse's arms.
• 10 months – can recognize their name and when spoken to,
listen intently.
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 CARE OF MOTHER, CHILD AT RISK | NCM 109
CHAPTER 29: NURSING CARE OF A FAMILY WITH AN INFANT

• 9 months – are very aware of changes in tone of voice. ▪ This gentle rhythm of care gives infants a sense of
o They cry when scolded, not because they understand what being able to predict what is going to happen and
is being said, but because they sense their parent's gives life consistency.
displeasure. • It is also important that the care be mainly given by one person
• 12 months – most children have overcome their fear of or by a core group of people.
strangers and are alert and responsive when approached. PROMOTING INFANT SAFETY
o They like to play interactive nursery rhymes and rhythm • Unintentional injuries are a leading cause of death in children
games and "dance" with others. from 1 month through 24 months of age.
o They also like being at the table for meals and joining in
ASPIRATION PREVENTION
family activities.
• Aspiration is a chief injury threat to infants throughout the first
COGNITIVE DEVELOPMENT year.
• In the first month of life, an infant mainly uses simple reflex
• Round, cylindrical objects are more dangerous than square or
activity. flexible objects in this regard.
• There is little evidence infants at this early age see themselves o A 1-in. (3.2-cm) cylinder, such as a carrot or hot dog, is
as separate from their environment. particularly dangerous because it can totally obstruct an
o However, this does not mean they cannot respond actively infant's airway.
or interact with people. o A deflated balloon can be sucked into the mouth,
o They demonstrate that they are very people-oriented obstructing the airway in the same way.
moments after birth by cuddling against an adult's chest.
• Other instances of aspiration occur because caregivers
PRIMARY AND SECONDARY CIRCULAR REACTION underestimate their infant's ability to grasp and place objects
• 3 months – child enters a cognitive stage identified by Piaget in their mouth.
(1952) as primary circular reaction. o Newborns' grasp and sucking reflexes automatically cause
o During this time, the infant explores objects by grasping them to grasp and pull the object into their mouth.
them with the hands or by mouthing them (Fig. 29.14). • A test of whether a toy could be dangerous if an infant puts it
o Infants appear to be unaware of what actions they can inside the mouth is whether it fits inside a toilet paper roll. If it
cause of what actions occur independently. does, it is small enough to be aspirated.
• 6 months – infants pass into a stage Piaget (1952) called • Offer small pieces of hot dogs or grapes, not large chunks.
secondary circular reaction. • Children under about 5 years should not be offered popcorn or
o Now when infants reach for a mobile above the crib, hit peanuts because of the danger of aspiration.
it, and watch it move, they realize it was their hand that
FALL PREVENTION
initiated the motion, and so they hit it again.
• Falls are also a major cause of infant injuries.
• 10 months – discover object permanence.
• No infant, beginning at the newborn stage, should be left
o Infants are ready for peek-a-boo once they have gained
unattended on a raised surface.
this concept.
• Normal wiggling can bring even a newborn to the edge of a
• 1st year – capable of reproducing new events (they deliberately
bed, couch, or table top, resulting in a fall.
hit a mobile once, it moves, and they hit it again).
o They drop objects from a high chair or playpen and watch • Teach caregivers to be prepared for their infant to turn over by
where they fall or roll. 2 months of age.
o Caregivers must be especially vigilant not to leave the
THE NURSING ROLE IN HEALTH PROMOTION OF AN INFANT baby unattended on a changing table or counter.
AND THEIR FAMILY o If the child sleeps in a crib, the mattress should be lowered
PROMOTING ACHIEVEMENT OF THE DEVELOPMENTAL TASK: to its bottom position so the height of the side rails
TRUST VERSUS MISTRUST increases; rails should be no more than 2⅜ in. apart,
• Erikson (1993) proposed that the developmental task of the narrow enough so that children cannot put their head
infant period is to form a sense of trust between them.
• Infants who have numerous caregivers, who may be fed one o Two months is about the maximum length of time infants
day on a rigid schedule and the next only when they are can safely sleep in a bassinet; they need the protection of
hungry, who sometimes are treated roughly and sometimes a crib and high side rails before they turn over.
gently, or who do not always have their needs met can have • Make sure there is no space between the mattress and
difficulty learning to trust. headboard or an infant's head could become trapped.
• It is important for infants to establish the ability to love, or • Make sure cords from nursing call bells or other equipment are
trust, early in life in this way because development is out of an infant's reach.
sequential. If a first developmental step is not achieved, this can CAR SAFETY
affect all future steps.
• Infants should be placed in backward-facing seats in the back
• Trust arises primarily from a sense of confidence that one can seat because an inflating front seat airbag could suffocate an
predict what is coming next. infant (AAP, 2015b).
o Parents/caregivers should study the infant's reaction to • Backward-facing car seats should continue to be used until the
activities and then establish a workable schedule based on child reaches the highest weight or height allowed by the car
that (e.g., breakfast, bath, play-time, nap, lunch, walk safety seat's manufacturer.
outside, quiet playtime, dinner, story, and bedtime).

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 CARE OF MOTHER, CHILD AT RISK | NCM 109
CHAPTER 29: NURSING CARE OF A FAMILY WITH AN INFANT

SAFETY WITH SIBLINGS • Toddler milks or toddler formulas should not be fed to infants.
• As infants become more interactive at about 3 months of age, • Cow's milk is not recommended prior to 1 year of age.
older siblings grow more interested in interacting with them. o The protein in cow's milk is difficult for an infant to digest
• Children under about 5 years, as a group, are not responsible • If human milk is unavailable, infants should be fed an iron-
enough or knowledgeable enough about infants to be left fortified commercial infant formula.
unattended with them. FEEDING FROM 6 MONTHS TO 1 YEAR
BATHING AND SWIMMING SAFETY • From 6 months to 1 year of age, continue to feed infants
• Do not leave an infant unattended in a tub, even when human milk through breastfeeding or in a bottle obtained
propped up out of the water or sitting in a bath ring or bath through expression through the first year of life, and longer if
seat. desired.
• Normal wiggling can easily cause a baby to slip down under • Infants fed human milk exclusively or a mixed feeding of
the water. human milk and formula need supplementation with Auoride
• Many communities offer infant swim programs for babies as and iron at 6 months of age
young as 6 months. This does not teach them to swim; • Feed infants iron-fortified infant formula during the first year
therefore, the parent/caregiver should not be overconfident of life when human milk is unavailable.
about their infant's ability to be safe in the water. • After 6 months of age, if the water supply does not contain
CHILDPROOFING fluoride, it may be provided to the infant as a supplement.
• As soon as infants begin teething at 5 to 6 months, they chew • Infants are not ready to digest complex starches until amylase
on any object within reach to lessen gumline pain. is present in saliva at approximately 2 to 3 months.
• Thoroughly check for possible sources of lead paint, such as • Biting movements begin at approximately 3 months.
painted cribs, playpen rails, or windowsills before this time to • Chewing movements do not begin until 7 to 9 months.
avoid lead poisoning. • Introduce infants to nutrient-dense complementary foods after
• If an infant is going to play on the floor, move furniture in front 6 months of age.
of electrical fixtures or buy protective caps for outlets. • The entire first year of life is one of extremely rapid growth, so
• Install safety gates at the top and bottom of stairways as a high-protein, high-calorie intake is necessary.
additional safety measures before the infant crawls. o Calorie allowances can be gradually reduced during the
• Move all potentially poisonous substances from bottom first year from a level of 120 calories per kilogram (55
cabinets and store them well out of their infant's reach. calories per pound) of body weight at birth to
• Infants of any age should not be left unattended in carriages, approximately 100 calories per kilogram (45 calories per
high chairs, grocery shopping carts, or strollers. pound) of body weight at the end of the first year.
• Baby walkers are extremely dangerous because infants can • Infants are capable of approximating their lips to a cup, and
maneuver them near stairways and fall. they can drink effectively from one at about 9 months of age.
• When infants begin creeping, remind caregivers to recheck • The sucking reflex begins to diminish in intensity between 6
bottom cabinets and stairways for safety. When the child and 9 months.
begins to walk, higher areas, such as low tables, need to be • At approximately 6 months of age, infants become interested
cleared of dangerous items. in handling a spoon and begin to feed themselves.
• 10 months – achievement of a pincer grasp makes infants able DEVELOPMENTAL READINESS FOR BEGINNING TO EAT
to pick up very small objects: Remind caregivers to check play SOLID FOODS
areas or areas such as tabletops for pins or other sharp objects • Typically, between ages 4 and 6 months, infants develop the
that could be swallowed. gross motor, fine motor, and oral skills necessary to begin to
• When walking begins around this time, additional childproofing eat complementary foods.
measures need to be considered, including attention to the • Signs that an infant is ready for complementary foods include:
infant's access to open doors and stairs (Fig. 29.17). 1. Being able to control the head and neck
PROMOTING NUTRITIONAL HEALTH OF AN INFANT 2. Sitting up alone or with support
FEEDING FROM BIRTH THROUGH 6 MONTHS 3. Bringing objects to the mouth
4. Trying to grasp small objects, such as toys or food
• Provide human milk exclusively via breastfeeding or expression
5. Swallowing food rather than pushing it back out onto the
and stored in a bottle.
chin
o Human milk is the ideal form of nutrition for infants.
▪ It provides all the necessary nutrients, protective PROMOTING INFANT DEVELOPMENT IN DAILY ACTIVITIES
factors against disease, and properties that support BATHING
infant health and growth and development. • Except in very hot weather, an infant does not need a bath
▪ Infants exclusively receiving human milk or partial every day.
human milk feedings (supplemented with formula) • Some infants do need their head and scalp washed frequently
should receive 400 IU of vitamin D supplement daily (i.e., every day or every other day) to prevent seborrhea, a
starting at 2 weeks of age (AAP, 2017). scaly scalp condition often called cradle cap (Smith, 2020).
▪ Infants exclusively on formula do not need vitamin D o If seborrhea lesions develop, they adhere to the scalp in
supplementation as it is included in the formula. yellow, crusty patches.
▪ It provides immunity from infections from which the o The skin beneath them may be slightly erythematous.
breastfeeding parent is immune. o The patches can be softened by oiling the scalp with
mineral oil and removed by shampooing the hair.
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 CARE OF MOTHER, CHILD AT RISK | NCM 109
CHAPTER 29: NURSING CARE OF A FAMILY WITH AN INFANT

o A soft toothbrush or fine-toothed comb can be used to • Infants should not sleep in a semireclined position, such as a
help remove the yellow, crusty patches. swing or car seat, as it decreases oxygen levels when the head
• Bath time should be enjoyable for an infant. falls forward, and it may worsen gastroesophageal reflux.
• Especially beginning at 6 months, the infant plays during bath • Swaddling can help if the baby has a sensitive startle reflex, as
time. they will awaken when startled.
DIAPER-AREA CARE o Swaddling should be loose enough that the adult’s fingers
• The most effective means of promoting good diaper-area can be inserted under the material over the chest, so it
hygiene is to change diapers frequently, about every 2 to 4 does not impede their chest rise with breathing.
hours while the infant is awake. o Swaddling should be discontinued at 2 months and no
• If an infant develops a rash from sleeping in wet diapers, air- later than when the infant can roll over at 4 months to
drying or sleeping without a diaper may be a solution. reduce the risk of suffocation.
• At each diaper change, wash the skin with clear water or a EXERCISE
commercial alcohol-free (and perfume-free if an infant has • Infants benefit from being outdoors in the stroller because
sensitive skin) diaper wipe and then pat or allow the skin to sunlight provides a natural source of vitamin D.
air-dry. • In hot weather, caution caregivers to protect an infant from sun
• Do not use baby or talc powder, as it is a potential source of exposure.
aspiration. o The sun is most intense between 10 a.m. and 3 p.m., so
• Following a diaper change, hand hygiene is required. early mornings and late afternoons are the best times for
DENTAL CARE infants to be outside.
• Fluoridated water is an effective way to promote healthy tooth • Use of sunscreen is not recommended in children until they are
formation and prevent tooth decay. at least 6 months old.
o A water level of 0.3 ppm fluoride in water is • In addition to providing fresh air, going for walks while pointing
recommended. out the sights of the world - trees, birds, dogs, houses,
• Toothbrushing can begin even before teeth erupt by rubbing a neighbors - help children develop language and allows for
soft washcloth over the gum pads. quality time with a parent.
o This eliminates plaque and reduces the presence of • The use of walkers is not recommended because infants can be
bacteria. seriously injured if the walker is near a stairway and they fall
• Once teeth erupt, all surfaces should be brushed with a soft the length of the steps.
brush or washcloth once or twice a day. PROMOTING HEALTHY FAMILY FUNCTIONING
• Toothpaste is not necessary for an infant because it is the TEETHING
scrubbing that removes the plaque. An initial dental checkup • Most infants have little difficulty with teething, though the
should be made around 1 year of age and continued at 6- eruption of the molars may cause some fussiness.
month intervals until adulthood. • Generally, gums are sore and tender before a new tooth breaks
DRESSING the surface.
• Clothing for infants should be easy to launder and simply o Because of this pain, infants can be resistant to chewing
constructed, so neither dressing nor undressing is a struggle. for a day or two and be slightly cranky, possibly because
• When they begin to creep, infants need long pants to protect they are a little hungry from not eating as much as usual.
their knees. • Teething rings that can be placed in the refrigerator or freezer
• Until they begin to walk, they need only soft-soled shoes or to provide soothing coolness against tender gums.
merely socks or booties to keep their feet warm. • An infant who is teething will place almost any object in the
• Even when they begin walking, the soles of their shoes need mouth to chew on, so have caregivers ensure all toys and other
only be firm enough to protect their feet against rough objects within reach are safe.
surfaces and nonskid to prevent slipping. • Infant or children's liquid acetaminophen (Tylenol) may be
• Extremely hard soles and high ankle sides are unnecessary. given for teething discomfort after checking with the primary
care provider for the correct dose.
SLEEP
• Infants from birth to 3 months sleep an average of 14 hours. THUMB-SUCKING
• Tummy time should be continued until the infant is rolling over • Many infants begin to suck a thumb or finger at about 3
consistently at around 4 months of age. months of age and continue the habit through the first few
• 4 months – lower the crib mattress to the lowest level in years of life.
anticipation of the infant pulling up to a standing position. • The sucking reflex peaks at 6 to 8 months, whereas thumb-
• From 3 to 12 months, infants sleep an average of 13 hours a sucking peaks at about 18 months.
day. • Thumb-sucking is common and does not deform the jaw in
o Naps decrease from every 3 to 4 hours to one to two naps infancy.
a day to 1 to 2 hours each. USE OF PACIFIERS
• 6 months – sleeping longer stretches, for 6 to 8 hours. • If the infant is not given a pacifier and has a strong need to
o Establish a bedtime routine and put infants to sleep while suck, they will suck on their finger or thumb.
they are awake, so they can learn to console themselves. • Benefits of pacifiers include that they may provide comfort to
• 9 months – may have some night waking. the infant, aid in pain relief, and decrease the risk of SIDS.

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 CARE OF MOTHER, CHILD AT RISK | NCM 109
CHAPTER 29: NURSING CARE OF A FAMILY WITH AN INFANT

• Risks associated with pacifier use are possible negative impact • Constipation may occur in formula-fed infants because formula
on breastfeeding if given prior to breastfeeding being well has a higher curd-to-whey ratio and is more difficult for the
established, and dental malocclusion, particularly if usage is infant to digest.
greater than 2 to 3 years. • When infants are stooling, their faces do turn red, and they
• An infant who completes a feeding and still seems restless and grimace and grunt. As long as stools are not hard and contain
discontented, who actively searches for something to put into no evidence of fresh blood (as might occur with a rectal fissure),
the mouth, or who sucks on hands and clothes may benefit this is not constipation but typical infant behavior.
from a pacifier. • If hard bowel movements are present beyond 5 or 6 months of
• Attempt to wean a child from a pacifier any time after 3 age, check with the infant's primary healthcare provider about
months of age and certainly during the time the sucking reflex measures to relieve this.
is fading at 6 to 9 months. Weaning after this age is difficult. • All infants with a history of constipation (i.e., hard and
HEAD BANGING infrequent stools) should be examined for an anal fissure or
• Some infants rhythmically bang their head against the bars of tight anal sphincter.
a crib for a period before they fall asleep, an action that can be • Hirschsprung disease (aganglionic megacolon, or lack of nerve
a distressing behavior. innervation to a portion of the colon) may be manifested
• Head banging in this limited fashion - beginning during the during infancy as constipation.
second half of the first year of life and continuing through to o Take a careful history to assess for other symptoms of
the preschool period, associated with nap-time or bedtime, Hirschsprung disease: ribbonlike stools, diarrhea, and a
and lasting under 15 minutes - can be considered normal. distended abdomen.
o Children use this measure to relax and fall asleep. • Chronic constipation also may occur in children with congenital
• Pad the rails of cribs so infants cannot hurt themselves and hypothyroidism (decreased functioning of the thyroid gland).
reassure them this is common for the relief of tension in • An infant with constipation should be carefully observed for
children of this age. characteristic signs of hypothyroidism: lethargy, protruding
tongue, and failure to meet developmental milestones.
SAFE SLEEP DURING INFANCY
• Safe sleep recommendations include putting the infant to LOOSE STOOLS
sleep on their back until they can roll over on their own; not • Stools of breastfed infants are generally softer than those of
swaddling the infant once they can roll over; not putting formula-fed infants.
anything in the crib (e.g., blankets, pillows, crib bumper, • Occasionally, loose stools may begin with the introduction of
wedges) for the first year; using a crib or bassinet; using a solids.
pacifier at naps and bedtime once breastfeeding is well • A concerning reason for loose stools is celiac disease or the
established; and ensuring a smoke-free environment. inability to process gluten (sometimes termed malabsorption
• The AAP (2021) does not recommend bed sharing. syndrome).
• Bed sharing is defined as an infant sharing an adult bed with o The inability to digest fat and fat-soluble vitamins,
an adult for sleep. Co-sleeping may include bed sharing or accompanied by a distended abdomen, is another
sleeping in close proximity. common symptom of celiac disease and requires further
o When breastfeeding parents sleep with their infants, they evaluation.
protect their children from potential physiologic stressors COLIC
like airway covering and overheating. • Colic is paroxysmal abdominal pain that generally occurs in
• Hazardous risk factors and certain circumstances during bed infants under 3 months of age and is accompanied by loud,
sharing can increase the risk of SIDS. intense crying.
o These include sharing a sofa or chair with a sleeping • Infants pull their legs up against their abdomen, their faces
adult; the infant sleeping next to an adult who is a smoker become red and flushed, their fists clench, and their abdomens
or is impaired by alcohol or drugs; the infant sleeping in become tense.
the supine position; the infant never initiating • If offered a bottle, an infant with colic will suck vigorously for a
breastfeeding; sleeping on a soft mattress; and an infant few minutes and then stop as another wave of intestinal pain
who is preterm or of low birth weight. occurs.
o It is recommended that when bed sharing, the bed should • The cause of colic is unclear and probably results for several
be away from walls and furniture to prevent wedging the reasons.
infant's head or body between the bed and the wall; the • It may occur in susceptible infants from overfeeding or from
mattress should be firm without thick covers; the infant swallowing too much air while feeding.
should not be left alone on an adult bed; the adult should o Formula-fed infants tend to have more symptoms than
use the C-position (cuddle curl) with the infant's head breastfed infants do, possibly because they swallow more
across from the adult's breast, with the adult's legs and air while drinking or because formula is more difficult to
arms curled around the infant; and the infant should be digest.
sleeping on their back away from pillows. • Offering a pacifier can be comforting. Reducing stimuli, taking
CONSTIPATION infants for car rides, or playing a music box that simulates the
• Breastfed infants are rarely constipated because their stools sound of a heartbeat are often reported as being helpful.
tend to be naturally loose and frequent. • Dietary changes, such as protein hydrolysate formula, may
improve symptoms of colic in formula-fed infants.

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 CARE OF MOTHER, CHILD AT RISK | NCM 109
CHAPTER 29: NURSING CARE OF A FAMILY WITH AN INFANT

SPITTING UP • Eliminating sweating by reducing the amount of clothing on an

• Almost all infants spit up, although formula-fed infants have a infant or lowering the room temperature should result in
higher incidence than breastfed infants, possibly due to almost immediate improvement and prevent further eruptions.
overfeeding. BABY-BOTTLE TOOTH DECAY SYNDROME
• The infant who spits up a mouthful of milk (rolling down the • Putting an infant to bed with a bottle can result in decay of all
chin) two or three times a day (or sometimes after every meal) the upper teeth and the lower posterior teeth.
is experiencing average, early-infancy spitting up. • Decay occurs because, while an infant sleeps, liquid from the
• Associated signs such as diarrhea, abdominal cramps, fever, propped bottle continuously soaks the upper front teeth and
cough, rhinorrhea, or loss of appetite or activity suggest lower back teeth (the lower front teeth are protected by the
illness. tongue).
• If an infant (usually age 2 to 8 weeks) is spitting up so forcefully • The problem, called baby-bottle syndrome, is most serious
that milk is projected 3 or 4 ft away, it may be pyloric stenosis when the bottle is filled with sugar water, formula, milk, or
(an abnormally tight valve between the stomach and fruit juice.
duodenum).
• If the spitting up is a large amount with each feeding, it may
indicate gastroesophageal reflux, in which a lax cardiac
sphincter and esophagus allow for the regurgitation of gastric
contents into the esophagus.
• Burping the baby thoroughly after a feeding may decrease
spitting up.
• Parents/caregivers may try sitting an infant in an infant chair
for half an hour after feeding.
• Spitting up decreases in amount as the infant becomes better
at coordinating swallowing and digestive processes (the cardiac
sphincter matures).
• After a few months, the infant will naturally stay in an upright
position longer, and gravity will help to correct the problem.
DIAPER DERMATITIS (DIAPER RASH)
• The infant may need more frequent diaper changes as stools in
contact with may cause irritation.
• Urine that is left in diapers too long breaks down into
ammonia, a chemical extremely irritating to infant skin.
o Ammonia dermatitis of this type is generally a problem in
the second half of the first year of life, when an infant is
producing a larger quantity of urine than before.
• Frequent diaper changing, applying an ointment, and exposing
the diaper area to air may relieve the problem.
• If a diaper area is covered with lesions that are bright red, with
or without oozing, that last longer than 3 days, and appear as
red pinpoint lesions, suspect a fungal (monilial or candidiasis)
infection that will also need therapy (an antifungal medicine
such as Nystatin).
• Whenever the entire diaper area is erythematous and irritated,
it is suggestive of an allergy to the material in the diaper or to
laundry products of a commercially washed or home-washed
diaper.
o Changing the brand or type of diaper or washing solution
usually alleviates this problem.
MILIARIA
• Miliaria, or prickly heat rash, occurs most often in warm
weather or when infants are overdressed or sleep in
overheated rooms.
• Clusters of pinpoint, reddened papules with occasional
vesicles and pustules surrounded by erythema usually appear
on the neck first and may spread upward to around the ears
and onto the face or down onto the trunk.
• Bathing an infant twice a day during hot weather, particularly
if a small amount of baking soda is added to the bath water,
may improve the rash.

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