1. INFANCY

2. Learning Objectives: INFANCY
1. To know the period covered by infancy 2. To know the characteristics of infancy 3. To know the characteristics of the neonate 4. To know the hazards of infancy 5. To know the normal & abnormal physical examination findings of a neonate 6. To know the milestones in the newborn Ref: Molnar, Pediatric Rehabilitation, ch. 1 &2

3. Review: Stages/Periods of Dev/Life Span
10 Stages Life Span 7 Periods
Prenatal Prenatal
INFANCY INFANCY
Babyhood Childhood
Early Childhood Adolescence
Late Childhood Young adulthood
Puberty Middle Adulthood
Adolescence Older Adulthood
Early Adulthood
Middle Age
Old Age
8 Periods Life Span
Prenatal
INFANCY & Toddlerhood
Early Childhood
Middle Childhood
Adolescence
Young Adulthood
Middle Age
Late adulthood

4. INFANCY Subdivisions of Infancy: birth to 2nd week of life
Period of Partunate (from birth to 15 mins to 30mins after birth)
- begins when the fetal body has emerged from the mother’s body and
last until the umbilical cord has been cut & tied.
- Or the peripartum period (parturition=birth)
Neonate (from the cutting/tying of the umbilical cord to approx the
end of 2nd week of postnatal life)
- birth to 28 days
- period when existence of an individual begins; makes adjustments to
the new environment

5. INFANCY CHARACTERISTICS: Shortest of all developmental period
Time of radical adjustments
Plateau in development
Preview of later development
Hazardous period

6. Characteristics of Infancy
Shortest of all Developmental Period
Time when the fetus must adjust to life outside the uterine walls of the mother where it has lived for 9 mos.
Medical criteria- adjustment completed with fall of
umbilical cord from navel
Physiologic criteria- when infant has regained the
weight lost after birth
Psychological criteria- when infant begins to show signs
of developmental progress in behavior

7. Characteristics of Infancy
Time of Radical Adjustments
Physiologic Changes in the Newborn
Shift of blood circulation
Onset of respiration
Temperature changes
Weight loss
Nutrition
Elimination

8. Characteristics of Infancy
Time of Radical Adjustments
Adjustments to Postnatal Life:
Temperature changes- constant temp of 100F in uterine
sac, while temp outside varies.
Breathing- infant must begin to breathe on their own
when umbilical cord is cut
Sucking & swallowing- infant gets nourishment thru these
instead of receiving thru umbilical cord
Elimination- when infant begins to show signs of
developmental progress in behavior

9. Characteristics of Infancy
Time of Radical Adjustments
Indications of Difficult Adjustments to Postnatal Life:
Loss of weight- due to difficulty in swallowing &
suckling
Disorganized behavior
- irregularities in breathing rate, frequent urination &
defecation, wheezing, regurgitation
- due to pressure on the brain during birth, results in a
stunned state & partly to underdeveloped state of the
autonomic nervous system which controls body
homeostasis

10. Characteristics of Infancy
Plateau in Development
Slight regression: weight loss, less strong & healthy than
at birth
Due to necessity for making radical adjustments to
postnatal environment
Preview of Later Development
Hazardous Period
Physically- difficulties making radical adjustments to
new environment
Psychologically- time when attitudes of significant people
toward infant are crystallized

11. Conditions Influencing Adjustment to Postnatal Life
Prenatal Environment
Kind of birth
Experiences associated with Birth
Length of Gestation Period Conditions
Parental Attitudes
Postnatal Care

12. Prenatal vs. Postnatal Life
Characteristic
Prenatal life
Postnatal life
Environment
Amniotic fluid
Air
Temperature
Relatively constant
Fluctuates with atmosphere
Stimulation
Minimal
All senses stimulated by various stimuli
Nutrition
Dependents on mother’s blood
Depending on external food & functioning of digestive system
Oxygen supply
Passed from maternal bloodstream via placenta
Passed from neonate’s lungs to pulmonary blood vessels
Metabolic elimination
Discharged by skin, kidney, lungs & gastrointestinal tract

13. The NEWBORN Neonatal Period (first 4 wks of life) Size appearance
Body systems
The Brain
The Reflexes

14. Neonatal Characteristics
Physical/Physiologic:
average wt: 3000 gms ; length: 50 cms
head is ¼ of total body length (vs 1/7 in adults)
respiration: cycles
heartbeat: more rapid than adults
hunger demands are irregular
elimination

15. Neonatal Characteristics
Sensory Capacity
Vision
fixed focal length of 8-12 inches( usual distance from breast to the mother’s face
inborn visual preference for faces
minimal color vision due to underdeveloped cones
Hearing
well developed
can discriminate direction, pitch and intensity
preference for female voices

16. Neonatal Characteristics
Smell
well developed, can distinguish odors and react to it
Taste
well developed, can distinguish sweet, sour, salty stimuli
Organic (physiologic) sensitivity
hunger and thirst
Tactile sensitivity
touch, pressure and temperature

17. Neonatal Characteristics
Activities
Mass activities- mass activity occurs thru out entire body when an area is stimulated.
Specific activities- involve certain limited areas; reflexes & generalized responses.
Vocalization
Crying
Explosive sounds
Sensitivities- motor response to sensory stimuli

18. Neonatal Characteristics
State of consciousness
- some disorganization more conscious of surroundings
Emotions
- complete absence of graduation of responses showing different degrees of intensity resultant emotion intense and sudden
Beginnings of personality
- born with characteristic temperament

20. Common Characteristics of all Neonates
Size
Body proportions
Lack of body homeostasis
Two types of activity- mass & reflex
Inability to communicate, except thru crying
Underdeveloped sensitivities, except for smell
& taste
A blurred state of consciousness
Limited capacity for learning
Underdeveloped emotions
Beginning of individuality

21. Newborn: Medical & Behavioral Screening
Immediate Medical Assessment
- The APGAR Score
Neonatal Screening for Medical Conditions
Assessing Responses: The Brazelton Scale

22. Newborn Examination FULL TERM INFANT PRE-TERM INFANT APGAR
Neurological Examination
Neonatal Behavioral Assessment Scale
Skeletal System Examination
Range of Motion
Reflexes
PRE-TERM INFANT
Neonatal Behavioral Assessment Scale (NBAS)
Assessment of Premature Infant Behavior (APIB)
Newborn Individualized Development Care & Assessment
of Progress (NIDCAP)
Test of Infant Motor Performance (TIMP)
Hi there!

23. APGAR Score Sign 1 2 Appearance (color) Blue, pale1 2
Appearance
(color)
Blue, pale
Body pink, extremities blue
Entirely pink
Pulse
(heart rate)
None/0
Slow (< 100)
Rapid (>100)
Grimace
(reflex irritability)
No response
Coughing , sneezing, crying
Activity
(muscle tone)
Limp, flaccid
Some flexion activities, weak, inactive
Active motion, strong, active
Respiration
(breathing)
Absent
Irregular, slow
Good, crying
TOTAL
(0-3:severe distress) 5
(4-6:moderate difficulty) 10
(7-10; absence of stress)

24. HAZARDS of Infancy Physical Hazards Prenatal environment
- substance abuse, malnutrition
Type of birth & Complications
Vaginal delivery
- breech, compound, instrumental (forceps)
Caesarian delivery
Multiple births
Postmaturity & prematurity

25. Stages of Labor Stages Characteristics
Stage 1: Effacement-thinning/shortening & dilatation of the cervix
Produced by uterine contractions that force the amniotic sac against the cervical canal like a wedge, or if the membranes has ruptured, then pressure will be exerted by the presenting part of the fetus , usually the head
This stage ends when the cervix is fully dilated
Contractions beginabout10minutes apart
Stage 2: delivery of the fetus
Also assisted by uterine contractions, but most important force provided by increased intra-abdominal pressure form contractions of abdominal muscles
Contractions may occur less than 1 minute apart and last from 30 to 90 seconds
Stage 3: delivery of the placenta
& fetal membranes
Uterine contractions & aided by increasing intra-abdominal pressure

26. Stages of Labor 1st Stage: longest, about 12 hrs for primigravida
- uterine contractions cervix
dilates.
2nd Stage: about 1 ½ hrs or less
- babys head move thru cervix
 vaginal canal emerge from
mother’s body  born 
cut/clamp umbilical cord.
3rd stage: about 5-30minutes
- placenta & remaining cord
expelled.
4th Stage: after delivery; mother
rests, monitor recovery

27. - the buttocks appears first, followed by the legs & finally the head.
Method of Delivery
Natural or Spontaneous birth
- the position of the fetus & its size in relation to thee mother’s reproductive organs allow it to emerge in the normal head first position.
Breech birth
- the buttocks appears first, followed by the legs & finally the head.
Transverse birth
- fetus is positioned crosswise in the uterus. Instruments used for delivery unless position changes before birth.
Instrument birth
- fetus is too large to emerge spontaneously or when its position makes normal birth impossible, then instruments used to aid in delivery.
Caesarian Section
- fetus surgically removed thru the mother’s abdomen

28. Complications of Childbirth
Birth Trauma
- injury sustained at time of birth due to anoxia, diseases or infections or mechanical injury.
Low Birthweigth/Maturity
Weight: Low birthweigth = weigh less than 2,500 grams
Very low birthweigth= weigh grams or less
Small-for-date: may/may not be preterm but weigh less
Causes:
1) demographic factors- race, age, education & status
2) medical factors predating pregnancy- infections, bleeding
3) prenatal behavioral & environmental factors- poor nutrition,
inadequate prenatal care, smoking, alcohol & drug use,
exposure to stress or to toxic substances.
Maturity: Premature = born before 37th week of gestation
Postmature= born 2-5 wks after due date or >42 weeks AOG
*size complicates delivery

29. Effects of Prematurity
Physical- smaller, “sickly”
Developmental Lag- till 2-3 yrs old; slower to sit, stand, walk & talk
Sensory Behavior- highly sensitive to noise, colors & moving objects
 more distracted
Motor control- awkward & poor posture
Speech development- slower to develop, baby talk persist longer
Intelligence- mental defects due to brain injury
Socialization- poorer social adjustments, persist to adolescence
Emotional behavior- common

30. Prematurity vs Postmaturity
smaller
developmental lag
poor motor control
delayed speech
lower IQ
poor socialization
apathetic
greater morbidity and mortality
POSTMATURITY
bigger
greater risk of physical trauma at birth
hyper-reactive

31. Hazards of Infancy Psychological Traditional beliefs Helplessness
Individuality
Developmental lag
Plateau in development
Lack of stimulation
New parent blues
Names

32. Physical Examination of a Newborn Infant
Vital signs:
Temp: °C
Pulse rate: beats/min
Respiratory rate: breaths/min
BP if necessary
Weight, length, head circumference, (chest circumference, abdominal circumference)
General Appearance: activity (sleeping, crying vigorously or motionless) ; tone; posture, level or consciousness

33. SKIN
Vernix , color, texture (presence of cyanosis, mottling, pallor, jaundice or plethora), presence
of rashes
Hemangiomas : “Stork bites” – macular hemangiomas usually seen in occipital area,
glabella & eyelids.
Spontaneously disappears
within the 1st year of life

34. SKIN Mongolian spot - Dark blue or purple bruise-like macular Milia
spots usually located over the sacrum.
Present in 90% of Blacks & Asian;
disappear by 4 years of age.
Milia
- rash with tiny pin-head sized, sebaceous,
retention cysts usually on the chin, nose
& forehead. Disappears within a few
weeks after birth

35. SKIN
Erythema toxicum
- numerous small areas of red skin with a yellow-white papule in the center. Noticeable at 48 hours after birth to about 7 days of age. Staining of the papule shows eosinophils. Resolves spontaenously.

36. HEAD AND NECK Appearance & shape of head, size of fontanelles,
Caput succedaneum- diffuse edematous
swelling of soft tissue of the scalp that may
extend across the suture lines.
Cephalhematoma
- subperiosteal hemorrhage that never extends or
crosses the suture line, secondary to traumatic
delivery. Results to hyperbilirubinemia at times;
resolves within 6 wks.

37. Neural Tube Defects: Anencephaly- a NTD in which the cranial folds fail to close, leading to tissue degeneration and little or no formation of higher brain centers

38. HEAD & NECK Craniosynostosis - premature closure of one or more
sutures of the skull resulting to an
asymmetric skull
Craniotabes
- softening of the skull usually occuring around the suture lines & disappears within days after birth. May persist in pathologic conditions like calcium deficiency, syphilis and osteogenesis imperfecta

39. HEAD & NECK Neck: - presence of webbing
(Noonan’s or Turner’s syndrome)
presence of thyroglossal duct cyst
- facial assymmetry

40. HEAD & NECK Mouth: palate, tongue, throat Hard/ soft palate
- presence of cleft lip or
palate or both
- Epstein pearls: gingival cysts of newborn

41. CHEST & LUNGS Symmetry, pectus, breast hypertrophy
Hypertrophy: commonly seen in the 1st 3 days of life,
due to maternal hormones.
Presence of milk: normal ( witch’s milk), due to
maternal hormones.
Supernumerary nipples, inverted nipples or widely
spaced nipples.
Breathsounds & breathing patterns
Bronchovesicular breath sounds
Grunting
Weak persistent cry or groaning usually appreciated on expiration; pathologic

42. HEART Heart sounds, heart rate, pulses ABDOMEN
Murmurs
Dextrocardia
ABDOMEN
Presence of masses or organomegaly; bowel
sounds
Liver palpable: 2 cm below R rib margin
Abdominal wall defects:umbilical hernia, omphalocoele

43. ABDOMEN
Obvious defects like omphalocele, gastroschisis , diaphragmatic hernia as manifested by a scaphoid abdomen
Gastroschisis
Congenital defect of the abdominal
wall involving evisceration of the
abdominal contents

44. GENITALIA Presence of ambiguous genitalia
Males
- normally phimotic, average penile length > 2 cm
- check for the position of the meatus: hypospadias,
- presence of hydrocele, hernia, descended testes
Females
- labia and clitoris
- fused labia & enlarged clitoris  suspect adrenal hyperplasia
- mucosal tags are commonly attached to the vaginal wall
ANUS and RECTUM
Check for patency to rule out imperforate anus

45. EXTREMITIES Arms and legs with special attention to the digits
Syndactyly
- Abnormal fusion of the digits, most
commonly involve the 3d & 4th fingers
and the 2nd & 3rd toes
Polydactyly
- Supernumerary digits on hands or feet;
associated with a strong family history

46. TRUNK and SPINE Check for gross defects of the spine
Presence of abnormal pigmentation on the lower back should increase the probability of underlying vertebral problems

47. HIPS
Check for congenital hip dislocation; common in white females & more likely to be unilateral.
Clinical signs:
1) asymmetry of the skin fold
2) shortening of the affected leg
Ortolani’s maneuver
Abduct the hips by using gentle inward & upward pressure over the greater trochanter.
Barlow’s maneuver
Adduct the hips by using the thumb to apply outward & backward pressure over the inner thigh.

48. NERVOUS SYSTEM Muscle tone Reflexes Hypotonia Hypertonia
Floppiness and head lag
Hypertonia
Increased resistance is apparent when the extremities are extended
Reflexes

49. NERVOUS SYSTEM Reflexes Rooting reflex Glabelar/ blink reflex
Stroking the lip & corner of the mouth  infant turning to that direction with an open mouth
Glabelar/ blink reflex
Tap the forehead  the eyes will blink
Grasp reflex
Place a finger in the palm of the infant  infant will grasp the finger
Neck righting reflex
Turn the infants head to either side  movement of the contralateral shoulder.
Moro reflex
Support the infant behind the upper back with one hand & drop the infant back abduction of both arms & extension fingers

51. Growth and Development
Growth – increase in physical size and dimensions relative to maturity
Development – the acquisition and refinement of advancing skills
Developmental Milestones: areas of function
Gross motor behavior
Fine-motor adaptive
Language behavior
Personal –social behavior

52. Developmental Milestones
Areas of Function:
Gross-motor behavior- pre ambulatory skills, walking, and advance physical activities
Fine motor-adaptive behavior- prehension, manipulatory hand skills and application of sensorymotor abilities to task of daily life
Language behavior- vocalization, comprehension, expression in spoken or other modes of communication
Personal-social behavior- acquisition of societal and cultural standards of behavior

53. Cognitive Development: - refers to increasing ability of the child to interpret sensory events; register & retrieve information from memory; and manipulate schemata, images, symbols & concepts in thinking, reasoning, problem solving and the acquisition of knowledge & beliefs about the environment
Stages:
Sensorimotor stage
Preoperational stage
Stage of concrete operational thought
Formal operational thought

54. Cognitive Development
Stages
Characteristics
Sensorimotor stage
(Birth-18 months)
Spans transition from immature reflex & sensorimotor responses to purposeful activity by the formation of increasingly complex sensory & motor abilities
Allow infants to organize & exercise some control over their environment
Preoperational stage
(begins to learn language to 6-7 years)
Develop the tools for representative schemes symbolically through language, imitation, imagery, symbolic play & drawing.
Acquire capacity to deal with objects 7 events not present in the immediate situation
Stage of Concrete Operational Thought (6-7 to 11 years)
Formal education: develop logical thinking & can manipulate groups of categories, classification system & hierarchies
Formal Operational Thought
(11 t0 12 years)
Ability to conceptualize about many simultaneous interacting variable, use abstract reasoning & develop hypothetical theories

55. Milestones in Child Development: Newborn
Gross Motor
Fine Motor Adaptive
Personal/
Social
Speech & language
Cognitive
Emotional
Flexor tone predominate
In prone, turns head to side
Automatic reflex walking
Rounded spine when held sitting
Hands fisted
Grasp reflex
State-dependent ability to fix & follow bright object
Habituation & some control of state
Cry
State –dependent quieting & head turning to rattle or voice
Sensrorimotor :0-24 mos
Reflex stage
Basic trust vs. Basic mistrust
Normal-symbiotic phase- does not differentiate self & mother

56. Summary: INFANCY
1st 2 wks of life: period of partunate & period of neonate
5 characteristics:
a) shortest d) preview of later dev
b) time of radical change e) hazardous period
c) plateau in dev
4 adjustments to postnatal life:
a) to temperature changes, c) to breathing
b) to sucking & swallowing d) to elimination
Difficulty of adjustment shown by:
a) weight loss
b) disorganized behavior c) infant mortality

57. Summary: INFANCY Conditions influencing adjustment:
a) prenatal environment d) postnatal care
b) length of gestation e) parental attitudes
c) kind of birth
Common chac among infants:
a) size g) underdeveloped emotions
b) body proportions h) blurred state of consciousness
c) lack of body homeostasis i) limited learning capacity
d) types of activity-mass & reflex j) beginning
e) inability to communicate individuality
f) underdeveloped sensitivities

58. Summary: INFANCY
Unfavorable prenatal environment & difficult uncomplicated birth are hazardous to normal development
Conditions influencing adjustment:
a) prenatal environment d) postnatal care
b) length of gestation e) parental attitudes
c) kind of birth
Common characteristics among infants:
a) size g) underdeveloped emotions
b) body proportions h) blurred state of consciousness
c) lack of body homeostasis i) limited learning capacity
d) types of activity-mass & reflex j) beginning
e) inability to communicate individuality
f) underdeveloped sensitivities

59. Summary: INFANCY
Unfavorable prenatal environment & difficult uncomplicated birth are hazardous to normal development
Conditions influencing adjustment:
a) prenatal environment d) postnatal care
b) length of gestation e) parental attitudes
c) kind of birth
Common characteristics among infants:
a) size g) underdeveloped emotions
b) body proportions h) blurred state of consciousness
c) lack of body homeostasis i) limited learning capacity
d) types of activity-mass & reflex j) beginning
e) inability to communicate individuality
f) underdeveloped sensitivities

60. Summary: INFANCY Growth & development: I. Developmental milestones
II. Cognitive development
Newborn milestoness:
a) gross motor
b) fine motor adaptive
c) personal-social
d) speech & language
e) cognitive
f) emotional