Handouts for Normal Pediatrics

CONCEPTS OF GROWTH AND DEVELOPMENT
Definition of Terms • GROWTH • DEVELOPMENT physical change and increase in size measured QUANTITATIVELY ex: eight, weight, bone size, dentition, etc. 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 I. Prenatal Ovum Embryo Fetus II. Natal Premature/Preterm Mature/Term III. Postnatal Neonate Infant Toddler Preschooler School Age Adolescence 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 0 – 18 months 1 8 months – 3 years 3 – 6 years 6 – 12 years 12 – 18 years GROWTH PERIOD Infancy Toddler Preschool School Age Adolescence STAGE/S Oral Stage Anal Stage Phallic. Oedipal Stage Latency Stage Genital Stage TIME RANGE 0 – 280 days 0 – 14 days 14 days – 9 wks 9 wks - birth 23 – 37 weeks 37 – 42 weeks 0 – 28 days 0 – 1 year 1 – 3 years 3 – 6 years 6 – 12 years 12 – 18 years

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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)

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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 0 – 1 year 1 – 3 years 3 – 6 years 6 – 12 years 12 – 18 years

GROWTH PERIOD Trust vs. Mistrust Autonomy vs. Shame & Doubt Initiative vs. Guilt Industry vs. Inferiority Identity vs. role Confusion

STAGE/S Optimism Self-Control/Will Power Direction & Purpose Method & Competence 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 Age Span 1 mo 1-4 mo Nursing Implications Stimuli are assimilated into beginning mental images. Behavior entirely reflexive Hand-mouth and ear-eye coordination develop. Infant 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: I Infant learns to initiate, recognize, and repeat pleasurable experiences from environment. Memory traces are present; infant anticipates familiar events (a parental coming near him will pick him up). Good toy for this period: mirror: good 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 separateness, infant experiences separation anxiety when primary caregiver leaves. Good toy for this period: nesting toys (i.e., colored boxes), Child is able to experiment to discover new properties of

Stage of Development Sensorimotor Neonatal reflex Primary reaction circular

Secondary reaction

circular

4-8 mo

Coordination of secondary reactions

8-12 mo

Tertiary reaction

circular

12-18 mo

Invention of new means through mental combinations Preoperational Thought

18-24 yr

2-7 yr

7-12 yr Concrete Operational Thought

12 yr Formal Thought Operational

objects and events Capable of space perception and time perception as well as permanent. Objects outside self are understood as causes of actions. Good game for this period: throw and retrieve. Transitional phase to the preoperational thought period, Uses memory and limitation to act. Can solve basic problems; foresee maneuvers that will succeed of fail. 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 reversibility (for every action there is an opposite action) is present. Unable to state cause-effect relationships, 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 shape or position). Good activity for this period: collecting and classifying natural object such as native plants, 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

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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

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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 3 – 5 years No concept of death Developing awareness of separation and loss First death-related perceptions? “All gone”; “peek-a-boo” games 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 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 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 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.

6 – 9 years

10 & older Adolescence

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

Score Interpretation: 0 - 3 Resuscitation ASAP! 4 - 6 guarded → Continuous monitoring & suctioning

7 -10  Best possible condition

2. Gestational Age Assessment (BESTS) Criteria B – reast nodule E – ar lobe S – calp hair T – estes/Scrotum S – ole creases 0.36 weeks 2 mm No cartilage Fine and fuzzy Testes in lower sac; scrotum with no rugae Anterior transverse crease only 37-38 weeks 4 mm Some cartilage Fine and fuzzy Intermediate; scrotum with some rugae Creases over anterior 2/3 39 weeks & above 7 mm Thick cartilage Coarse and silky Testes pendulous; scrotum with rugae Entire sole covered 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

3. 4. 5. 6. 7. 8. 9. 10. 11.

buttocks; disappear by SCHOOL AGE. Vernix caseosa - cheese-like material; serves as insulator Lanugo - fine, downy hair at shoulders, back and upper arms; disappear by 2 weeks. Milia - plugged or unopened sebaceous gland on the cheek or across the bridge of the nose; disappear by 2-4 weeks 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. Erythema toxicum - aka fleabite.rash; pink papules with vesicles seen at nape, back and buttocks; appears usually 2nd day; no treatment needed. Nevus flammeus - aka portwine stain; red to purple in color; do not blanch on pressure and do not disappear. Strawberry hemangioma - elevated areas formed by immature capillaries and endothelial cells; complete disappearance by 10 yrs old. Cavernous hemangiomas - dilated vascular spaces; do not disappear with time. 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 Cause Extent of Involvement Absorption Caput succedaneum Scalp edema Both hemispheres (Crosses sutures) About 3 days Cephalhematoma Collection of blood between periosteum and skull bone Does not cross sutures 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

H. Mouth I.

obligate nasal breathers

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)

J.

K.

L.

M.

N.

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 Chest should be symmetrical breasts may be engorged WITCH'S MILK: due to maternal hormones You may hear rhonchi 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) 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 Back appears flat when prone mass, hairy nebule or a dimple along axis – this is seen in Spina bifida 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 Foramen ovale Ductus arteriosus Ductus venosus Umbilical arteries (2) Umbilical vein (1)

Functional Closure 1 year 1 month 2 months 2-3 months 2-3 months

Adult structure Fossa ovalis Ligamentum arteriosum Ligamentum venosum Lateral umbilical ligament Ligamentum teres (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

5.

receives IgG from mother (passive natural immunity) no immunity from chickenpox and herpes simplex

Senses Touch – the most developed sense 6. Neuromuscular System Neonatal Reflexes Reflexes Rooting reflex Sucking Reflex Extrusion Reflex Palmar grasp Stepping (Walk-in-place/Dancing) Reflex Placing (**anterior surface of leg) Plantar, grasp Tonic neck (Fencing/Boxer) Reflex Moro reflex Barbinski Reflex Magnet Reflex Crossed Extension Reflex Trunk Incurvation Reflex Landau Reflex (Parachute Reaction) Bauer's (Crawling) Reflex Blink Reflex (see objects 9-12" at midline) Swallowing Reflex Disappearance 6 weeks 6 months 4 months 6 weeks-3 months 3 months 3 months 8-9 months 2-3 months 4-5 months 3 months 3 months 3 months 2-3 months 3 months 6 weeks Do not disappear 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 CHON COOH Minerals Iron High (Lactose) Low (Lactalbumin/Whey) Same (Linoleic Acid) Low Low Low High (Casein) Sam e High Low

Table 6.1 COMPOSITION OF MATURE HUMAN MILK AND COW MILK Composition Water (ml/dl) Energy (kcal/dl) Total solids (g/d!) Protein (g/dl) Fat (g/dl) Lactose (g/dl) Ash (g/dl) Human Milk 87.1 75 12.9 1.1 4.5 6.8 0.2 Cow Milk 87.2 66 12.8 3.5 3.7 4.9 0.7 Composition Serine Tyrosine Major minerals per liter Calcium (mg) Phosphorus (mg) Sodium (mEq) Potassium (mEn) Human Milk 69 61 340 140 7 13 Cow Milk 160 17S 1170 920 22 35

Protein (% of total protein) Casein Whey proteins Nonprotein nitrogen (mg/dl) % Of total nitrogen) Amino acids (mg/dl) Essential Histidine Isolellcine Leucine Lysine Methionine Phenylalanine Threonine Tryptophan Valine Nonessential Arginine Alanine Aspartic acid Cystine Glutamic acid Glycine Proline

Chloride (mEq) 40 60 32 15 82 13 32 6 Magnesium (mg) Sulfur (mg) Trace minerals per liter Chromium (ug) Manganese (ug) Copper (ug) Zinc (mg) Iodine (ug) Selenium (ug) Iron (mg) Vitamins per liter Vitamin 1 (I.V.) Thiamine (ug) Riboflavin (ug) Niacin (ug) Pyridoxine (ug) Pantothenate (mg) Folacin (ug) BI2 (ug) Vitamin C (mg) Vitamin D (LV.) Vitamin E (mg) Vitamin K (ug) -

11 40 140

29 120 303

--7-15 .400 3-5 30 13-50 0.5 1898 160 360 1470 100 1.84 52 0.3 43 22 1.8 15

8-13 20-40 30 3-5 47 5-50 0.5 1025 440 1750 940 640 3.46 55 4 11 14 0.4 60

22 68 100 73 25 48 50 1.8 70 45 35 116 22 230 0 80

95 228 350 277 88 172 164 49 245 129 75 166 32 680 11 250

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: Underdeveloped SC tissues; thin-skinned Mgt: Incubator Temp 33.3 - 34.4°C Humidity 55-65% Position on right side Poikilothemlic Take axillary’s temperature not rectal to decrease energy expenditure Exaggerated weight loss Frog-like position CNS centers for respiration underdeveloped 02 inhalation (Never more than 40% → Retrolental fibroplasia) 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

1.

2. 3. 4. 5. 6.

POSTMA TURE NEWBORN Born after the 42nd week of gestation Characteristics: 1. "Old man's" facies 2. Weight loss 3. Dehydrated

4. 5. 6. 7. 8. 9. 10.

Chronic Hypoxia Hypoglycemia Long and thin With cracked skin Stained with meconium Long nails; firm skull 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 female 10 kg (22 lbs) 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 A reliable criterion for growth since this is not affected by excess fat or fluid. reflects growth failure and chronic under nutrition

B. Height -

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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 3-6 mos 6-9 mos 9-12 mos 9 cm 8 cm 5 cm 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 Next 8 mos 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) ½ inch per month ¼ inch per 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 Intracellular Extracellular • 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 INFANT 40% 35% ADULT 40% 20%

The higher the EC, the more prone to dehydration should illnesses like diarrhea occur.

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 HEARING TOUCH TASTE Teach parents to make eye-to-eye contact with the infant to Infants enjoy mobiles and crib mirror Photos of family members may be posted near the baby's crib. 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. 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. 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 stimulate vision and to promote socialization.

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 1.2 Sphincter control – myelination of nerve tract occurs at around 15 – 18 months of age (MOST IMPORTANT REQUIREMENT) 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 18 mos – 24 mos 2 –3 years 3 – 4 years start of training bowel control daytime bladder control 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 15 - 18 months 24 months drinks from a cup which he himself holds holds his own spoon with much spilling 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

AGE
3 years

MOTOR
Stands on one foot for at least one second. Jumps from bottom stair. Alternates feet going upstairs. Pours from a pitcher.

LANGUAGE

.PERSONAL-SOCIALADAPTIVE

Repeats six syllables, Understands taking turns. for instance: "'1 have a little dog” Copies a circle (from model, without demonstration). Names three to more objects in a picture. Builds three-block pyramid.

Can undo two buttons. Pedals a tricycle.

Gives sex. ("Are you a Dresses with supervision. boy or a girl?"). Puts 10 pellets into bottle in 30 . seconds. Gives full name. Repeats three digits (one of three trials). Knows a few rhymes. Gives appropriate answer to: "What: swims-flies-shootsPlays interactive games, such as "tag". Separates easily from mother. Feeds self well.

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 Stands on one foot for at least five seconds (two of three trials Repeats ten-word sentences without errors. Copies cross demonstration. (+) without

Counts three correctly.

objects,

pointing

Imitates oblique cross (x) Draws a man with four parts.

Hops at least twice on one foot. Can walk heel-totoe for four or more steps (with heel one inch or less in front of toe).

Repeats three to four digits (4-5 years).

Cooperates with other children in play.

Comprehends: "What do you do if: you are hungry, sleepy, cold?" Spontaneous sentences, four to five words long. Likes to ask questions.

Dresses and undresses self (mostly without supervision). Brushes teeth, washes face Compares lines: “Which is longer?”

Can button coat or dress; may lace shoe

Understands prepositions, such as: on-under-behind, etc. ("Put the block on the table."). Can point to three out of four colors (red, blue, green, yellow). Speech is now communicative tool an effective

Folds paper two to three times. Can select heavier from lighter object. Cares for self at toilet

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

Balances on one foot for eight to ten seconds. Skips, using feet alternately. May be able to tie a knot. Catches bounced ball with hands (not arm) in two of three trials.

Copies a square. Copies oblique cross (x) without demonstration

May print a few letters (5-5112 years). Draws a man with at least six identifiable parts. Performs three tasks (with one command) for instance: “Put pen on table-close door bring me the ball.” Knows four colors. Define use for: Fork-horse-key-pencil, etc. Identifies by name: Nickel-dime-peny. Builds a six-block pyramid from demonstrations Transports things in a wagon Plays with coloring set, Constructions toys, puzzles. Participates well group play

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 - play house - dolls puppets - housekeeping toys 4. ACTIVE - "doctor or .nurse" sets - 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

3. DRAMATIC/IMITATIVE

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. 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. Broadens his appreciation of the avenues of self-expression through art, music and

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 1214 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). 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"). B. Concerns of boys

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 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 years.

- 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 3. May have mood swings. 4. With fantasy and daydreaming 5. Needs consistent discipline LIMIT BEHAVIOR may also have anxiety regarding fear of rejection.

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§ 13 years *full of "self-doubt" *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 years *They leave childish behavior they used in early adolescence (shoving and punching to get attention of the opposite sex) *"Sweet Sixteen" phenomenon *both sexes trust their bodies 17

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 c. fad diets and false dieting 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 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. CHON synthesis and release of somatotropic hormone happen when a person sleeps. OBESITY ANOREXIA NERVOSA and BULIMIA

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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