Physical Development

Newborn assessment begins with a determination of gestational age using the Dubowitz/Ballard exam or similar gestational age scale (see Chapter 38). It is important to document significant prematurity, intrauterine growth restriction (IUGR), and size for gestational age (i.e., either large for gestational age [LGA] or small for gestational age [SGA]). Comparisons are made between the reported gestational age, birthweight and length, and head circumference.

The infant may initially lose up to 5% to 8% of birthweight but should regain it within 10 to 14 days. Weight loss of 10% or more requires close monitoring and may require further evaluation. Weight gain after the initial loss averages 0.5 to 1 ounce (14 to 28 g) per day, or about 2 pounds (1 kg) per month. Nutritional needs to promote growth are about 110 kcal/kg/day (see Chapter 10).

The stability of the infant’s autonomic nervous system can be evaluated through heart rate, respiratory rate, temperature control, and color changes. The infant should demonstrate some degree of regulation of state and ease of transitions from deep sleep through quiet alert to active alert and crying. A variety of techniques can be used to arouse the newborn for feedings. The newborn sleeps about 16 out of 24 hours and, if encouraged to breastfeed every 2 to 3 hours, may have one longer stretch of 4 hours at night. It is important to assess for a normal-pitched cry because problems such as hypothyroidism and genetic disorders (e.g., cri du chat syndrome) can cause voice alterations.

Motor Skills Development

The newborn’s flexed posture provides the infant with the ability to self-console when positioned so that the hands reach the face and mouth. Primary reflexes, such as sucking, rooting, asymmetric tonic neck, Moro, and grasp, should be present and symmetric. Passive muscle tone is evaluated within gestational age scales through observation of shoulder (scarf sign) and knee flexibility (popliteal angle). Arm and leg recoil provide information about the infant’s active movements, particularly symmetry and coordination. Jerkiness and tremors may be noted. The neonatal period begins a remarkable series of fine and gross motor skill milestones for the infant (Table 5-1).

TABLE 5-1 Fine Motor and Gross Motor Development Milestones for Infants and Preschoolers

Communication and Language Development

The newborn gives clear signals of distress, such as crying, arching, or gagging. These help the caregiver respond to the infant’s needs. The newborn should be able to habituate to sound and light. Newborns use self-consoling or self-calming behaviors, such as sucking, moving hand to mouth, or grasping clothing.

Articulation, or the way that the structures of the nose and mouth mold the sounds emitted by the larynx, begins at birth with the infant’s first cry. In the first few weeks of life, infants make sounds of comfort and discomfort.

Social and Emotional Development and Maternal Postpartum Depression

Social skills are evident as the newborn quiets readily, turns to the parent’s voice, and demonstrates a brief smile. Using a soft voice, touching, and picking up the baby are ways the caregiver consoles the newborn.

Social and emotional development is closely linked to the mother’s emotional state—60% to 80% of mothers experience “baby blues” in the first 2 weeks of life, 10% to 15% have postpartum depression during the first year of the infant’s life, and 0.1% to 0.2% present with postpartum psychosis. Postpartum depression can occur anytime during the first year of the infant’s life, whereas postpartum psychosis generally presents in the first weeks after delivery. The rate of postpartum psychosis is significantly higher if there is maternal schizophrenia or bipolar disease, or when the mother’s history is positive for previous postpartum psychosis (Spinelli, 2009). The pediatric health care provider sees mothers frequently during the infant’s first year of life. Infants’ well-child visits should be used as opportunities to screen mothers and families for factors that can affect the infant’s growth and development including depression and intimate partner violence. A screening tool such as the 10-question Edinburgh Postnatal Depression Scale can be used to identify mothers needing further evaluation, referral, and close follow-up (Cox et al, 1987; Wisner et al, 2002) (see Chapter 38 for a copy of this scale).

Cognitive-Sensory Development

Vision is limited, but the newborn has the ability to focus briefly on a face or bright object when it is brought into visual range (about 8 to 12 inches from the infant’s face). Newborns visually track objects to midline. Of all the senses, the sense of smell is most acute in newborns. Hearing is also fairly well developed.

Physical Development

During months 1 through 3 the infant experiences many physical and developmental changes. Length increases about 1.4 inches (3.5 cm) per month and head circumference about 0.8 inch (2 cm) per month, with more rapid growth for the younger infant. The infant typically gains 0.5 to 1 ounce (14 to 28 g) per day and has 8 to 10 feedings in 24 hours, each lasting 20 to 30 minutes. Feedings lasting longer than 30 minutes need to be evaluated. At about 6 to 8 weeks, the infant may experience a growth spurt and fuss to eat more frequently. Mothers who are breastfeeding need extra encouragement during this time because they may believe that they do not have enough milk for their baby. Provider reassurance can be backed up by an interval infant weight check if the mother is overly concerned. Providers should instruct mothers to follow their infant’s cues for feeding; pointing out that the extra suckling will increase the milk supply sufficiently to meet their growing infant’s needs. Elimination patterns become more regular. Infants go from defecating with each feeding to having one or two bowel movements daily or every other day if formula fed, and bowel movements that range from once or twice daily to once every 3 to 5 days if breastfed. Wet diapers occur after each feeding.

Sleep cycles become more regular, about 15 to 16 hours per day, with defined sleep-wake patterns. The infant may need more organized play periods as sleep periods consolidate with consistent naps. Many infants have fussy periods in the late evening that may last 1 to 3 hours. Infant crying tends to peak at this age, but fortunately this fussiness usually lasts only a few weeks. Regular nap or nighttime routines help keep infants calmer. The provider should discuss with parents plans to cope with crying before this time is upon them. This is a good time to explain “shaken baby syndrome” to parents and encourage them and others who care for the infant to have a repertoire of coping skills.

Motor Skills Development

Fine motor skills begin to emerge as primitive reflexes become integrated. Infants attempt to grasp rattles, fingers, and clothing. They are able to demonstrate visible head control, lifting the head off the bed about 45 degrees when in the prone position and showing little head droop when held in suspension. All normal body movements are symmetric (see Table 5-1).

Communication and Language Development

Parents should be encouraged to notice how their infant looks at them when they are talking and how intently the infant looks at faces, especially during the quiet alert state, the time when the infant is most interactive. Infants “connect” with parents, even if only for a few moments. By talking to their infant during caregiving activities, parents encourage early language development. Infants start to make cooing and babbling sounds, much to the delight of their parents (Table 5-2 lists receptive and expressive language skills for children from birth to 5 years old). However, body movements (e.g., snuggling, turning the head, arching the body) continue to be the primary form of communication, and providers can help parents identify and become more skilled at interpreting their infant’s cues.

TABLE 5-2 Speech and Language Milestones: Areas for Surveillance

Social and Emotional Development

The infant becomes highly social, imitating the parent’s expressions and visually following the parent. Infants are more responsive to sounds in their environment, attending to sounds by quieting body movements or demonstrating visual responses. By three months, infants demonstrate a social smile and will usually smile in response to their parent’s voice. As infants become more active, alert, and responsive, parents may mistakenly assume that the infant can handle more activity and irregular stimulation than capable of managing. It is important for caregivers to develop sensitivity to infant cues for the need to rest or to have decreased stimulation.

Cognitive Development

By 4 to 8 weeks infants readily begin to take in more of their environment. When a face or toy is brought into visual range, the infant visually tracks past midline, vertically, and horizontally. Even very young infants demonstrate various facial expressions, respond to sounds, and attempt to imitate mouthing movements. By 3 months infants begin to enjoy toys and may wave their arms when a toy is brought into sight.

Physical Development

Infants 4 through 5 months old usually begin to settle into regular patterns of eating, sleeping, and playing. They sleep 12 to 15 hours a day with five feedings during the day and one during the night. By this age infants begin to sleep through the night without feeding. Somewhere between 4 and 6 months, infants double their birthweight, and slow growth to gain about 5 ounces (140 g) a week. Their length increases about 0.8 inch (2 cm) per month, and head circumference increases about 0.4 inch (1 cm) per month. Growth may appear in spurts although the overall growth chart will show a steady upward curve. Weight gain can be influenced by the amount of play activity and the sleep schedule. Although the infant’s primary source of nutrition comes from breast milk or formula, parents may ask about when to begin feeding solid foods. Many parents introduce some infant cereals by 4 months, but nutritionally, full-term babies need nothing other than breast milk or iron-fortified formula until 6 months old (see Chapter 10). As solid food is added, changes in stool consistency will be noted.

Motor Skills Development

Fine motor skills are demonstrated as infants play with their hands and begin to reach for and pull at clothing or other objects that are close. Eventually they grasp toys and begin to grab at other objects, such as the parent’s hair, earrings, or eyeglasses. They also start to place their hands on the breast or the bottle in an attempt to hold or pat it.

Motor skills progress (see Table 5-1) as the Moro and asymmetric tonic neck reflexes are integrated, and there is no longer the obligation of arm extension with head turning. The Landau reflex emerges. Infants who are given sufficient tummy time generally begin to roll, first from front to back and then from back to front. Head control becomes stronger and more sustained, and there should be no head lag when the baby is pulled to sit. When in the prone position, infants hold their head up at 45 degrees, gradually progressing to 90 degrees for sustained periods of time. The infant learns to sit, first in the tripod stance, then unassisted with the head held erect. When lying supine, infants are able to lift their legs and bring their feet to their mouth. They bear full weight when standing and enjoy bouncing up and down in a parent’s lap. All their body movements should be symmetric.

Communication and Language Development

Infants’ social skills increase and verbal skills become more evident (see Table 5-2). They begin babbling, using vowel sounds, cooing, and laughing quietly and experiment with variations in tone and pitch, such as low-pitched chuckles and deeper laughs. Eventually they laugh out loud, much to the enjoyment of those around them. Infants’ responses to sounds gradually become more localized, and they search for the sound of a bell or rattle.

Oral-motor development is a prerequisite for speech. Throughout infancy oral development progresses from sucking and rooting to rhythmic biting and chewing. Beginning at about 6 months and continuing through 2 years, the child learns to chew by moving the jaw up and down while flattening and spreading the tongue, and to control biting by using rotary jaw movements with lateralization of tongue placement. These motor skills, essential for the production of speech, are among the most complex movements that the young child must master.

Social and Emotional Development

During this time, infants’ social skills become more evident. Usual behavior includes spontaneous smiling at parents and others while visually following the caregiver around the environment and turning the head a full 180 degrees. At this age they promptly look at an object when it is placed in front of them; they notice things. The infant’s increasing awareness of the environment facilitates more complex social interactions. Infants begin to recognize that their parents are responding to their needs. They notice, for example, as the parent prepares to offer the breast or get a bottle ready for feeding. Because infants notice other things, parents can often distract them from demanding immediate gratification by talking, playing, or using other social interactions such as reciprocal vocalizations and eye contact. As a result, infants learn that their hunger needs will be met, but that there are other satisfying interactions they can have with their parents. Infants at this age begin to more actively reciprocate their parents’ attention and enjoy playing with their parents. Crying may reflect tiredness or a need for social interaction, not just hunger. Parents are able to acknowledge their child’s unique personality, and this reciprocal recognition is an important aspect of infant-parent attachment.

Cognitive Development

Visual exploration increases during this age, as infants seek out objects in the environment such as mobiles, mirrors, their hands, and the toys that they are holding. Their preference, however, is looking at their parents’ or another person’s face. Chewing and mouthing are other means of exploration used to differentiate textures, tastes, and shapes. As their muscle control improves, they are able to bring a toy to their mouth first when lying on their back and then when sitting.

Physical Development

As infants reduce their breast milk or formula intake and add solids to their diet, growth velocity changes. Weight gain slows to 3 to 4 ounces (85 to 110 g) a week, or about 1 pound (0.5 kg) a month; length gains are about 0.5 to 0.6 inch (1.2 to 1.5 cm) per month; and head circumference increases about 0.2 inch (0.5 cm) per month. If concerns about a large head circumference exist, note each parent’s head circumference and graph them to determine percentile for comparison with their infants, and continue to monitor the infant carefully (see Chapter 27 for a discussion of macrocephaly). Teething symptoms can begin at about 6 months as the central incisors emerge and at 8 months when the lateral incisors emerge. The first childhood illness might occur at the same time as teething behaviors start and these events can disrupt the infant’s previous sleep routine.

Motor Skills Development

Motor skills at this age need little encouragement for development because of the infants’ desire to explore the environment. Infants sit erect for longer periods of time and may scoot while in a sitting position. Crawling begins with the infant pushing up to the hands and knees and rocking in place, then eventually mastering the rhythm of hands and knees working together. Many infants will pull themselves along on the floor with their arms, and use one foot or toe to push while their stomachs remain on the floor, prior to beginning to use hands and knees to crawl. Infants may stand, fully supporting their weight, when their hands are held at shoulder height.

Fine motor skills continue to be honed, and babies are more adept at using their palm and all of their fingers to pick up objects. Initially they rake at small objects and are able to hold a small cube, lifting it off the table. Gradually they use fingers and thumb to pick up objects. They reach for and grasp toys, can hold a toy in each hand at the same time, and can transfer objects from one hand to another.

Communication and Language Development

Vocalizations continue to show increasing variety in pitch and tone, and imitation of specific speech sounds begins. Infants articulate single-sound units that may be vowels, consonants, or blends such as “ah,” “ba,” “da,” “ga,” “ch,” and “bl.” Gradually, they progress to double-consonant sounds (e.g., “dada”) and occasionally will vocalize using three or more different syllables. They use “mama” and “dada,” but not specifically for their parents. Infants can delight their parents as they respond to verbal cues and play at making sounds and noises when alone. They enjoy imitating oral sounds such as “raspberries” and coughing.

Although infants’ expressive language skills are limited, their receptive language is evident when they listen and respond to their parents’ talking. Infants distinguish facial expressions and gestures, may stop or quiet when their parent uses “no” or a different tone of voice, and turn toward their parents’ voices and other sounds, localizing directly to the sound.

It is important to encourage parents to begin reading to their child daily at a very young age, at least by 6 months, if not sooner. This can be introduced as part of the bedtime routine. Watching TV or videos should be discouraged because it is a passive medium, and infants learn language best when they interact with another person, by listening to parents’ voices and looking at a face that responds to them.

Social and Emotional Development

Infants at this age greatly enjoy social play, and their individual personality and temperament continue to be expressed. At times, infants’ increased ability to do things for themselves puts them at odds with their parents. Even if parents have learned to understand their infant’s cues and engage with the infant responsively, giving and taking and control issues can arise. Infants use gestures such as pointing, reaching with outstretched arms, tugging, and throwing things to get their parent’s attention and communicate their needs. As infants’ abilities and desires become more complex, and they expand their repertoire of communication cues, parents need to learn new parenting skills (e.g., how to handle a determined child) to meet their infant’s social development needs.

Stranger anxiety may appear at this time, depending on the variety of caregivers infants have had and their individual temperament.