Pediatric Growth & Development

Pediatric Growth & Development
Elizabeth Allen RN, MSN, CPN

Learning Objectives Upon completion of this activity the Learner will:
Identify pediatric age classifications and principles of development Compare the developmental theorists and summarize theories for each pediatric age group Recall major milestones in growth throughout the pediatric span Recall major milestones in development throughout the pediatric span Locate and utilize a growth chart as part of a pediatric assessment Recall general pediatric nutrition recommendations from the American Academy of Pediatrics and the USDA Locate and compare the DDST and PEDS developmental assessment tools Locate and utilize the CDC vaccination schedules in pediatric patients Compare a pediatric and adult physical assessment including a developmentally appropriate pain scale Interpret health and safety promotion among the pediatric population using developmental characteristics Use this power point to guide your reading. There is a lot of information in the text book and on the ATI resources. Use your time wisely. Please refer to the hyperlinks in the power point. We will have activities to do during class time that will require you to have a working knowledge of this material. Also, there will be a 5 point quiz at the start of each Tuesday class period. Please do not be late.

Principles of Growth & Development
Growth: increase in physical size Development: a qualitative increase in capability or function Unique to each individual Developmental Processes Cephalocaudal Proximodistal

Principles of Growth & Development
Age Classifications Classification Age Infant 0-12 month Toddler 1-3 years Preschooler 3-6 years School Age 6-12 years Adolescent 12-18 years

Developmental Theorists
Stage Erikson Piaget Freud Infant Trust vs. Mistrust Sensorimotor Stage Oral Stage Toddler Autonomy vs. Shame & Doubt End: Sensorimotor Begin: Preoperational Anal Stage Preschool Initiative vs. Guilt Preoperational Stage Phallic Stage School Aged Industry vs. Inferiority Concrete Operational Stage Latency Stage Adolescent Identity vs. Role Confusion Formal Operational Stage Genital Stage You will need to know this information both for the NCLEX and for patient care. You will be applying these principles every time you interact with a pediatric client

Kohlberg- Moral Development Stages of moral development with approximate ages- some may never reach final stage(s) Stage Age Preconventional 4-7 years Conventional 7-12 years Postconventional >12 years

Promoting Development through Play
Know developmental level and expectations Position appropriate for development Use appropriate, unbroken toys or games Speak at developmental level – remember receptive speech outpaces expressive in early years Social interaction as developmentally appropriate

Applying Developmental Theory to Nursing Care of Children What kinds of toys would be appropriate for clients of different ages/developmental levels? How is medication administration different for clients of different ages/developmental levels? Age is not always equivalent to developmental level Example: Conservation How would this apply to medication administration?

Growth- Infant Infant Measurement

Growth & Development- Infant
Body weight doubles by 5 months Body weight triples by end of 12 months Height increases by a foot in first year Affected by feeding/nutrition Solitary Play

0-2 month Gains g (5-7 oz.)/week Growth 1.5 cm (1/2 inch)/month Inborn reflexes- fists, rooting, startle Looks at faces 2-4 month Posterior Fontanelle closes Roll over Hold rattle, hands to midline Turn head to follow objects/sounds Pushes up on forearms when prone

4-6 months Doubles birth weight at 5-6 months Teeth begin to erupt Grows 1.5cm (1/2 inch)/month Grasps objects at will Manipulates objects Head held steady when sitting Supports most of weight when standing Vocalizes, laughs 6-8 months Growth rate slower than first 6 months Gains 3-5 oz/week Grows 1 cm (3/8 in.)/week Most newborn reflexes extinguished Sits alone Babbling Uses speech-like rhythm Responds to sounds and own name

8-10 months Same weight and height increases Pincer grasp Creeps or crawls Pull to stand approx. 10 months Babbles 1 word + “mama, dada” Understands “no” 10-12 months Head circumference equals chest circumference Triples birth weight by 1 year Stands alone, “walks” along furniture Sits from standing Places objects into holes Learns 1-2 words Receptive speech more developed

Growth & Development- Toddler
Growth rate slows Age 2: quadrupled birth weight and half of adult height By 33 months: all teeth erupted Toilet training

Growth- Toddler Growth Development
Gains average kg (3-6 lbs.)/year Grows cm(2-2.1 in)/year Undress self Throw ball Dresses self Scribble Runs Jumps Kick a ball Imitative play, likes to be around other children Several words to short sentences Receptive speech exceeds expressive Temper tantrums

Growth & Development- Preschooler
Gains kg(3-5 lbs.)/year Grows 4-6 cm( in)/year Associative (interactive) play Dramatic play Preoperational thought Vocabulary >2000 words Complete sentences of several words Dresses and feeds self Uses utensils Draws 6 part person

Growth & Development- School Aged
Body organs and immune systems mature- fewer illnesses, can better metabolize drugs, urinary system can better regulate fluid balance Long bone growth, decreased fat and more muscle Growth spurts in girls Tooth loss and permanent teeth erupt

Growth & Development- School Aged
Gains kg(3-5 lbs.)/year Grows 4-6 cm( in.)/year Girls may begin growth spurt 9-10 years Cooperative play Can read Concentrates for longer periods of time Mature use of language Sense of industry Ride a 2 wheel bike

Growth & Development- Adolescence
Puberty (sexual maturity) begins in later school ages and completes in adolescence Puberty versus growing Tanner Scale Growth spurt in girls approx. 10 years Growth spurts in boys approx. 13 years

Growth & Development- Adolescence Tanner Stages
Tanner Stages of Development of secondary sexual characteristics

Tanner Stages (American Academy of Pediatrics, 2008)

Growth & Development- Adolescence
Variation in age of growth spurt Girls: gain 7-25 kg(15-55 lbs.) grow cm(2-8 in.) Boys: gain 7-29 kg(15-65 lbs.) grow cm(5-12 in.) Formal operational thought Abstract reasoning Experiment with risky behaviors Establish identity and values Focus on Peer group Sexual maturity

Growth Charts From CDC (Centers for Disease Control)
Anthropomorphic Measurements Weight, length, head circumference Based on gender, age Specialized grids: i.e.. Trisomy 21 Percentiles Doesn’t account for ethnicity, immigration

Growth Charts Source: cdc.gov

Nutrition Resources American Academy of Pediatrics
USDA (U.S. Department of Agriculture) Choose Life Stages on R side of site

Nutrition- Infants Age Pattern Birth- 1 month 2-4 months 4-6 months
Breast or formula Q2-3 hrs 2-3 oz (60-90 ml)/feeding 2-4 months Breast or formula Q3-4 hrs 3-4 oz ( ml)/feeding 4-6 months Begin solids- rice cereal first, baby food Breast or formula 4 or more times per day 4-5 oz ( ml)/feeding 6-8 months Baby foods 2-3 times/day, 2-5 Tbs 6-8 oz( ml)/feeding 8-10 months Baby food, soft finger food TID Can use cup with lid- 6 oz per feeding 10-12 months Table foods with family TID Cup with lid, spoon

Assessment NUR251 Block 3

Developmental Assessment
Observation Interaction/Communication Assessment of developmentally appropriate tasks (ex. Preschooler draw 6 part person) Interview caregivers Compare to valid and reliable tool

Denver II Developmental Screening Tool Look for applicability, validity- including false positives and negatives, and method Refer to page in London et al. textbook or in text book of your choice

Parents’ Evaluation of Developmental Status Look for applicability, validity- including false positives and negatives, and method

Open Educational Resource Scroll to bottom of page Pediatrics: Developmental Stages ATI Online Resource: RN Review Modules Click on: Product Support Materials- RN Review Modules Editions- Nursing Care of Children 9.0 Health Promotion Chapters from Infant to Adolescent

Physical Assessment Vital Signs vary by age! (London et. Al., 2014)

Physical Assessment Infant Vital Signs
Infant heart rate and respiratory rates may be irregular Count respiratory rate for 1 minute Heart rate taken by apical pulse for 1 minute Location of apical pulse is different for children under 7 years. It’s located in the 4th intercostal space, L midclavicular line. After age 7 years, the apical pulse can be found in the same location as an adult.

Minimal Systolic Blood Pressure per Age
Physical Assessment Blood Pressure “Normal” blood pressure Minimal Systolic Blood Pressure per Age Age Systolic Blood Pressure Term neonates (0 to 28 days) >60 mm Hg Infants (1 to 12 months) >70 mm Hg Children 1 to 10 years (5th BP percentile) >70 mm Hg + (age in years x 2) mm Hg Children >10 years >90 mm Hg

Physical Assessment Blood pressure often deferred on children < 3 years Done in hospital, concerns BP cuff cover 2/3 of limb- upper arm or lower leg in young children

Physical Assessment Hypertension: defined by percentiles for Age & Height per National Heart Lung and Blood Institute Hypertension is defined as a reading >95th percentile for children of similar gender, age and height Hypertension is defined by a reading that is >95th percentile for children of the same gender, age and height. There isn't a simple target blood pressure reading that indicates high blood pressure in all ages for children, because what's considered normal blood pressure changes as children grow. In children years reading >90th percentile or greater than 120/80 indicate prehypertension

Physical Assessment Principles
Least invasive to most invasive Developmentally appropriate (ex. Talk directly to adolescent, get down to toddler’s eye level) Developmentally appropriate language Cultural competence Really similar to adult assessment!

Physical Assessment Across the room assessment-
the Pediatric Assessment Triangle

Physical Assessment Similar to adult, except in infant
Developmentally appropriate approach ATI videos are detailed, somewhat more detailed than what we will be doing in the hospital, but contain good information. We are preparing you to be a generalist and depending where you work you will learn to do a more detailed assessment as needed. I’m going to quickly cover some things that are not included in the videos and we’ll talk more in class.

Physical Assessment Infant Integumentary Assessment
Mongolian spots normal finding Abnormal Findings Sacral tuft of hair or dimple

Physical Assessment Occipital Frontal Circumference (OFC)
Birth to 3 years Measure of brain development, Neurological abnormalities and malnutrition Circumference should correlate with child’s length

Physical Assessment Ear Location
Line from outer edges of eye passes through the upper portion of the pinna Low seated ears are associated with chromosomal anomalies

Pain Assessment Developmentally appropriate tool
Valid and reliable for developmental level/age

Pain Assessment CRIES- Neonatal Pain Tool

Pain Assessment FLACC- nonverbal pain scale (London, et al., 2014)

Pain Assessment FACES Numeric Pain Scale (0-10) (London, et al., 2014)

Vaccinations Immunizations

CDC Schedule for Vaccinations
Follow these links to the recommended vaccine schedules published by the CDC. Please take a close look at what vaccinations are given in the first six months, which are given at 12 months of age, at 4-5 years of age and at 11 years of age. We’ll talk more about this in class.

Vaccinations Vaccine Adverse Event Reporting
Sponsored by the CDC and FDA When would you make a report? As a nurse or as a parent?

Vaccinations Children with moderate to severe illness, or high fever should not be vaccinated Some vaccines should not be given to immunocompromised patients HIV/AIDS, cancer, chemo or radiation therapy, steroid treatment Some vaccines not to give to immunocompromised patients include MMR, rotavirus, varicella/shingles

Vaccinations Which vaccines are live, attenuated virus vaccines and not given to immunocompromised patients? Who does not get the TdaP? What age group needs the Hib vaccination? Why? MMR and Varicella are live attenuated virus vaccines and not given to immunocompromised patients or patients that have received immunoglobulin in past 11 months.

Figure 18–5 Give immunizations quickly and efficiently
Figure 18–5 Give immunizations quickly and efficiently. Do not prolong the wait and let fear grow. The child will be anxious, especially if more than one injection must be given Vaccinations given in the vastus lateralis for the first 18 months. After that you may see immunizations given either in the deltoid or the vastus lateralis. (London et al., 2014)

Vaccinations Interventions Documentation Advocacy for immunizations
Information: benefits, risks, side effects Written and verbal Obtain consent Be efficient and use topical anesthetic and comfort measures Longer needles = fewer local reactions Date of Immunization Vaccine Given Manufacturer, Lot #, Expiration Date Site and Route of Administration Name/Title/Address of Nurse Information Given to Parents Immunization record, instructions for home Adverse effects: type, response

Health Promotion and Safety
Anticipatory Guidance

Based on Developmental Level How mobile is the child? Cognitive level? Height and coordination? Nutrition requirements? What hazards or injuries are typical at this age/developmental level? What screenings are recommended?

Primary prevention: keep healthy people from developing a disease or experiencing an injury in the first place Secondary prevention: interventions to halt or slow the progress of a disease if possible, limit long term disability or prevent re-injury Tertiary prevention: help chronically ill people to manage complicated, long term health problems and maximize quality of life

By age group: Infant: Bonding with caregivers Rolling over Putting things in their mouth Beginning to walk Nutrition, bottles and new teeth What topics or hazards should the nurse discuss with the family? What injury prevention strategies?

By age group: Toddlers More mobile Putting things in their mouth Nutrition- no longer getting formula Developing sense of self What topics or hazards should the nurse discuss with the family? What injury prevention strategies?

By age group: Preschoolers Active, developing coordination Exploring How do they travel? In a car seat?

By age group: School age Nutrition Physical Activity Social interactions Self esteem Academics What topics or hazards should the nurse discuss with the family? What injury prevention strategies?

By age group Adolescents Risk taking behavior! Sexual maturity Nutrition Physical Activity What topics or hazards should the nurse discuss with the family? What injury prevention strategies?

Pediatric Growth & Development

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