Health Promotion of the Infant and Family

Proportional Changes

During the first year, especially the initial 6 months, growth is very rapid. Infants gain 150 to 210 g (about 5 to 7 ounces) weekly until approximately age 5 to 6 months, when the birth weight has at least doubled. An average weight for a 6-month-old child is 7.3 kg (16 pounds). Weight gain slows during the second 6 months. By 1 year of age the infant’s birth weight has tripled, for an average weight of 9.75 kg (21.5 pounds). Infants who are breast-fed beyond 4 to 6 months of age typically gain less weight than those who are bottle-fed, yet head circumference is more than adequate. Dewey (2001) attributes the decreased weight gain seen in breast-fed infants to self-regulation of energy intake. This self-regulation of intake with breastfeeding (vs formula feeding) is believed to have further significance in the development of childhood obesity and subsequent cardiovascular disease (Grummer-Strawn, Mei, and Centers for Disease Control and Prevention, 2004; Schack-Nielsen and Michaelsen, 2006).

Height increases by 2.5 cm (1 inch) a month during the first 6 months and also slows during the second 6 months. Increases in length occur in sudden spurts, rather than in a slow, gradual pattern. Average height is 65 cm (25.5 inches) at 6 months and 74 cm (29 inches) at 12 months. By 1 year the birth length has increased by almost 50%. This increase occurs mainly in the trunk, rather than in the legs and contributes to the characteristic physique of the infant.

Head growth is also rapid. During the first 6 months head circumference increases approximately 1.5 cm (0.6 inch) per month, but the rate of growth declines to only 0.5 cm (0.2 inch) monthly during the second 6 months. The average size is 43 cm (17 inches) at 6 months and 46 cm (18 inches) at 12 months. By 1 year, head size has increased by almost 33%. Closure of the cranial sutures occurs, with the posterior fontanel fusing by 6 to 8 weeks of age and the anterior fontanel closing by 12 to 18 months of age (average 14 months).

Expanding head size reflects the growth and differentiation of the nervous system. By the end of the first year the brain has increased in weight about two and one half times. Maturation of the brain is exhibited in the dramatic developmental achievements of infancy (see Table 10-2). Primitive reflexes are replaced by voluntary, purposeful movement, and new reflexes that influence motor development appear.

The chest assumes a more adult contour, with the lateral diameter becoming larger than the anteroposterior diameter. The chest circumference approximately equals the head circumference by the end of the first year. The heart grows less rapidly than does the rest of the body. Its weight is usually doubled by 1 year of age in comparison with body weight, which triples during the same period. The size of the heart is still large in relation to the chest cavity; its width is approximately 55% of the chest width.

Maturation of Systems

Other organ systems also change and grow during infancy. The respiratory rate slows somewhat (see inside back cover) and is relatively stable. Respiratory movements continue to be abdominal. Several factors predispose the infant to more severe and acute respiratory problems than older children. The close proximity of the trachea to the bronchi and its branching structures rapidly transmits an infectious agent from one anatomic location to another. The short, straight eustachian tube closely communicates with the ear, allowing infection to ascend from the pharynx to the middle ear. In addition, the inability of the immune system to produce immunoglobulin A (IgA) in the mucosal lining provides less protection against infection in infancy than during later childhood.

The heart rate slows (see inside back cover), and the rhythm is often sinus arrhythmia (rate increases with inspiration and decreases with expiration). Blood pressure also changes during infancy (see inside back cover). Systolic pressure rises during the first 2 months as a result of the increasing ability of the left ventricle to pump blood into the systemic circulation. Diastolic pressure decreases during the first 3 months, then gradually rises to values close to those at birth. Fluctuations in blood pressure occur during varying states of activity and emotion.

Significant hematopoietic changes occur during the first year (see Appendix C). Fetal hemoglobin (HgbF) is present for the first 5 months, with adult hemoglobin steadily increasing through the first half of infancy. Fetal hemoglobin results in a shortened survival of red blood cells and thus a decreased number of red blood cells. A common result at 2 to 3 months of age is physiologic anemia. High levels of fetal hemoglobin are thought to depress the production of erythropoietin, a hormone released by the kidney that stimulates red blood cell production.

Maternally derived iron stores are present for the first 5 to 6 months and gradually diminish, which also accounts for lowered hemoglobin levels toward the end of the first 6 months. The occurrence of physiologic anemia is not affected by an adequate supply of iron. However, when erythropoiesis is stimulated, iron supplies are necessary for the formation of hemoglobin.

The digestive processes are relatively immature at birth. Although term newborn infants have some limitations in digestive function, studies indicate that human milk has properties that partially compensate for decreased digestive enzymatic activity, thus enabling the breast-fed infant to receive optimal nutrition during the first several months of life. Saliva is secreted in small amounts, but the majority of the digestive processes do not begin functioning until age 3 months, when drooling is common because of the poorly coordinated swallowing reflex. The enzyme amylase (also called ptyalin) is present in small amounts but usually has little effect on the foodstuffs because of the small amount of time the food stays in the mouth. Gastric digestion in the stomach consists primarily of the action of hydrochloric acid and rennin, an enzyme that acts specifically on the casein in milk to cause the formation of curds—coagulated semisolid particles of milk. The curds cause the milk to be retained in the stomach long enough for digestion to occur.

Digestion also takes place in the duodenum, where pancreatic enzymes and bile begin to break down protein and fat. Secretion of the pancreatic enzyme amylase, which is needed for digestion of complex carbohydrates, is deficient until about the fourth to sixth month of life. Lipase is also limited, and infants do not achieve adult levels of fat absorption until 4 to 5 months of age. Trypsin is secreted in sufficient quantities to catabolize protein into polypeptides and some amino acids.

The immaturity of the digestive processes is evident in the appearance of stools. During infancy, solid foods (e.g., peas, carrots, corn, raisins) are passed incompletely broken down in the feces. An excess quantity of fiber easily disposes the child to loose, bulky stools.

During infancy the stomach enlarges to accommodate a greater volume of food. By the end of the first year the infant is able to tolerate three meals a day and an evening bottle and may have one or two bowel movements daily. However, with any type of gastric irritation the infant is vulnerable to diarrhea, vomiting, and dehydration (see Chapter 24).

The liver is the most immature of all the gastrointestinal organs throughout infancy. The ability to conjugate bilirubin and secrete bile is achieved after the first couple of weeks of life. However, the capacities for gluconeogenesis, formation of plasma protein and ketones, storage of vitamins, and deaminization of amino acids remain relatively immature for the first year of life.

Maturation of the suckling, sucking, and swallowing reflexes and the eruption of teeth (see Teething, p. 342) parallel the changes in the gastrointestinal tract and prepare the infant for the introduction of solid foods.

The immunologic system undergoes numerous changes during the first year. The full-term newborn receives significant amounts of maternal immunoglobulin G (IgG), which, for approximately 3 months, confers immunity against antigens to which the mother was exposed. During this time the infant begins to synthesize IgG; approximately 40% of adult levels are reached by 1 year of age. Significant amounts of immunoglobulin M (IgM) are produced at birth, and adult levels are reached by 9 months of age. Secretory IgA is not present at birth but is found in saliva and tears by 2 to 5 weeks. IgA is present in large amounts in colostrum; IgA confers protection to the mucous membranes of the gastrointestinal tract (Lawrence and Lawrence, 2005) against many bacteria, such as Escherichia coli, and viruses such as rubella, poliovirus, and the enteroviruses. The development of the mucosa-associated lymphoid tissue (MALT) occurs during infancy; in part this system is believed to prevent colonization and passage of bacteria across the infant’s mucosal barrier (Lawrence and Lawrence, 2005). The function and quantity of T lymphocytes, lymphokines, interferon-γ, interleukins, tumor necrosis factor-α, and complement are reduced in early infancy, thus preventing optimal response to certain bacteria and viruses. The production of IgA and immunoglobulins D and E (IgD and IgE) is much more gradual, and maximum levels are not attained until early childhood.

There is evidence that vernix caseosa, a white oily substance that coats the term infant’s body and is often found in abundance in creases of the axilla and groin, has innate immunologic properties that serve to protect the newborn from infection (Narendran and Hoath, 2006). The epidermis of the full-term infant undergoes maturation during the first month of life; the newborn’s skin acts as a barrier to infection, assists in thermal regulation, and prevents transepidermal water loss in term infants.

During infancy, thermoregulation becomes more efficient; the ability of the skin to contract and of muscles to shiver in response to cold increases. The peripheral capillaries respond to changes in ambient temperature to regulate heat loss. The capillaries constrict in response to cold, conserving core body temperature and decreasing potential evaporative heat loss from the skin surface. The capillaries dilate in response to heat, decreasing internal body temperature through evaporation, conduction, and convection. Shivering (thermogenesis) causes the muscles and muscle fibers to contract, generating metabolic heat, which is distributed throughout the body. Increased adipose tissue during the first 6 months insulates the body against heat loss.

A shift in the total body fluid occurs; at birth 75% of the term infant’s body weight is water, and there is an excess of extracellular fluid. As the percentage of body water decreases, so does the amount of extracellular fluid—from 40% at term to 20% in adulthood. The high proportion of extracellular fluid, which is composed of blood plasma, interstitial fluid, and lymph, predisposes the infant to a more rapid loss of total body fluid and, consequently, dehydration.

The immaturity of the renal structures also predisposes the infant to dehydration and electrolyte imbalance. Complete maturity of the kidney occurs during the latter half of the second year, when the cuboidal epithelium of the glomeruli becomes flattened. Before this time the filtration capacity of the glomeruli is reduced. Urine is voided frequently and has a low specific gravity (1.000 to 1.010).

Auditory acuity is at adult levels during infancy. Visual acuity begins to improve, and binocular fixation is established. Binocularity, or the fixation of two ocular images into one cerebral picture (fusion), begins to develop by 6 weeks of age and should be well established by age 4 months. Depth perception (stereopsis) begins to develop by age 7 to 9 months but may not be fully mature until 2 or 3 years of age, thus increasing the infant’s and younger toddler’s risk of falling.

Fine Motor Development

Fine motor behavior includes the use of the hands and fingers in the prehension (grasp) of an object. Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. At 1 month of age the hands are predominantly closed, and by 3 months they are mostly open. By this time infants demonstrate a desire to grasp an object, but they “grasp” it more with the eyes than with the hands. If a rattle is placed in the hand, the infant will actively hold onto it. By 4 months of age the infant regards both a small pellet and the hands and then looks from the object to the hands and back again. By 5 months the infant is able to voluntarily grasp an object.

By 6 months of age infants have increased manipulative skill. They hold their bottle, grasp their feet and pull them to their mouth, and feed themselves a cracker. By 7 months they transfer objects from one hand to the other, use one hand for grasping, and hold a cube in each hand simultaneously. They enjoy banging objects and will explore the movable parts of a toy.

Gradually the palmar grasp (using the whole hand) is replaced by a pincer grasp (using the thumb and index finger). By 8 to 10 months of age the infant uses a crude pincer grasp and by 11 months has progressed to a neat pincer grasp (Fig. 10-1). By 10 months of age the pincer grasp is sufficiently established to enable infants to pick up a raisin and other finger foods. They can deliberately let go of an object and will offer it to someone. By 11 months they put objects into a container and like to remove them. By age 1 year, infants try to build a tower of two blocks but fail.

Gross Motor Development

Attachment

The importance of human physical contact to infants cannot be overemphasized. Parenting is not an instinctual ability but a learned, acquired process. The attachment of parent and child, which often begins before birth and assumes even more importance at birth (see Chapter 8), continues during the first year (Fig. 10-9). In the following discussion of attachment, the term mother is used in the broad context of the consistent caregiver with whom the child relates more than anyone else. However, with society’s changing social climate and sex-role stereotypes, this person may well be the father or a grandparent. Studies on paternal-infant attachment demonstrate that stages similar to maternal attachment occur and that fathers are more involved in child care when mothers are employed (although mothers continue to do the majority of infant care). Additional research has shown that inexperienced, first-time fathers are as capable as experienced fathers of developing a close attachment with their infants. Studies of fathers of high-risk infants demonstrate that fathers experience feelings of love and affection toward their offspring during the newborn period; fathers in one study verbalized more positive feelings of love and affection toward the newborn when they were able to have close physical contact such as holding the child (Sullivan, 1999). Children who had insecure attachment to their teenage mothers were found to have a strong attachment to the grandmother who was also a primary caretaker (Patterson, 1997). With many single-parent families in existence, a grandmother (or other significant caretaker) may become the primary caretaker. It is important for nurses to recognize that infant-parent attachments may be present or absent in situations wherein caretaker roles are less well defined by those involved.

Attachment progresses during infancy, with the child assuming an increasingly significant role. Two components of cognitive development are required for attachment: (1) the ability to discriminate the mother from other individuals, and (2) the achievement of object permanence. Both these processes prepare the infant for an equally important aspect of attachment: separation from the parent. Separation-individuation should occur as a harmonious, parallel process with emotional attachment.

During the formation of attachment to the parent, the infant progresses through four distinct but overlapping stages. For the first few weeks infants respond indiscriminately to anyone. Beginning at approximately 8 to 12 weeks of age, they cry, smile, and vocalize more to the mother than to anyone else but continue to respond to others, whether familiar or not. At approximately 6 months of age, infants show a distinct preference for the mother. They follow her more, cry when she leaves, enjoy playing with her more, and feel most secure in her arms. About 1 month after showing attachment to the mother, many infants begin attaching to other members of the family, most often the father.

Infants acquire other developmental behaviors that influence the attachment process. These include:

Reactive attachment disorder (RAD) is a psychologic and developmental problem that stems from maladaptive or absent attachment between the infant and parent and may persist into childhood and even adulthood (Wilson, 2001; Zeanah and Fox, 2004). Two different patterns of RAD have emerged: the emotionally withdrawn–inhibited pattern and an indiscriminate-disinhibited pattern (Zeanah and Fox, 2004). Signs of RAD are usually seen before the age of 5 years in infants who had insecure attachments to the mother or other primary caretaker (American Psychiatric Association, 2002). The child may manifest behaviors such as not being cuddly with parents, failing to make eye contact with significant others, having poor impulse control, and being destructive to self and others. Maltreated and orphaned children often are diagnosed with this complex disorder. Without early intervention, some of these children fail to develop a conscience and suffer from an antisocial personality disorder that may lead to criminal acts.

Language Development

The infant’s first means of verbal communication is crying. Crying as a biologic sign conveys a message of urgency and signals displeasure, such as hunger. However, crying is also a social event that affects the development of the parent-infant relationship—either by its absence, which usually has a positive effect on parents, or its presence, which may evoke a negative response or persuade parents to minister to the child’s physical or emotional needs.

In the first few weeks of life, crying has a reflexive quality and is mostly related to physiologic needs. Infants cry for 1 to 1½ hours a day up to 3 weeks of age and then build up to 2, and even 4, hours by 6 weeks. Crying tends to decrease by 12 weeks. It is thought that the increase in crying for no apparent reason during the first few months may be related to the discharge of energy and the maturational changes in the central nervous system. At the end of the first year, infants cry for attention, from fear (especially stranger fear), and from frustration, usually in response to their developing but inadequate motor skills.

Vocalizations heard during crying eventually become syllables and words (e.g., the “mama” heard during vigorous crying). Infants vocalize as early as 5 to 6 weeks of age by making small throaty sounds. By 2 months they make single vowel sounds such as ah, eh, and uh. By 3 to 4 months the consonants n, k, g, p, and b are added, and the infants coo, gurgle, and laugh aloud. By 8 months they imitate sounds, add the consonants t, d, and w, and combine syllables (e.g., “dada”), but they do not ascribe meaning to the word until 10 to 11 months of age (see Family Focus box). By 9 to 10 months they comprehend the meaning of the word “no” and obey simple commands. By age 1 year they can say three to five words with meaning. Because language development is based on expressive skills (ability to make thoughts, ideas, and desires known to others) and receptive skills (ability to understand the words being spoken), it is important that infants are exposed to expressive speech and that infants with delays in achieving milestones are carefully evaluated for potential hearing loss. (See Universal Newborn Hearing Screening, Chapter 8.)

Play

Play during infancy represents the various social modalities observed during cognitive development. The activity of infants is primarily narcissistic and revolves around their own body. As discussed under Development of Body Image (p. 330), body parts are primarily objects of play and pleasure.

During the first year, play becomes more sophisticated and interdependent. From birth to 3 months, infants’ responses to the environment are global and largely undifferentiated. Play is dependent; pleasure is demonstrated by a quieting attitude (1 month), a smile (2 months), or a squeal (3 months). From 3 to 6 months, infants show more discriminate interest in stimuli and begin to play alone with a rattle or a soft stuffed toy or with someone else. There is much more interaction during play. By 4 months of age they laugh aloud, show preference for certain toys, and become excited when food or a favorite object is brought to them. They recognize an image in a mirror, smile at it, and vocalize to it.

By 6 months to 1 year, play involves sensorimotor skills. Actual games such as peek-a-boo and pat-a-cake are played. Verbal repetition and imitation of simple gestures occur in response to demonstration. Play is much more selective, not only in terms of specific toys, but also in terms of “playmates.” Although play is solitary or one sided, infants choose with whom they will interact. At 6 to 8 months they usually refuse to play with strangers. Parents are definite favorites, and infants know how to attract their attention. At 6 months they extend the arms to be picked up, at 7 months cough to make their presence known, at 10 months pull the parent’s clothing, and at 12 months call them by name. This represents a tremendous advance from the newborn who signaled biologic needs by crying to express displeasure.

Stimulation is as important for psychosocial growth as food is for physical growth. Knowledge of developmental milestones allows nurses to guide parents regarding proper play for infants. It is not sufficient to place a mobile over a crib and toys in a playpen for a child’s optimum social, emotional, and intellectual development. Play must provide interpersonal contact and recreational and educational stimulation. Infants need to be played with, not merely allowed to play. Although the type of play infants engage in is called solitary, this is a figurative, not literal, term to denote one-sided play. The type of toys given to the child is much less important than the quality of personal interaction that occurs.

Table 10-1 lists play activities appropriate for the developmental level of the infant in view of motor, language, and personal-social achievements. Although the activities are grouped according to the major mode of stimulation provided, there is overlap in many instances. In addition, play activities suggested for one age-group may be appropriate for older infants but inappropriate for younger infants.

Childrearing Practices Related to Temperament

Most parents realize that their infant is born with unique characteristics, and few parents of difficult infants need to be told of the challenge of caring for them. However, few parents are aware of the significance of the temperamental characteristics and of constructive approaches to dealing with them. The following are examples of interventions that promote more positive parenting of infants with different temperament styles.^*

“Difficult” children may respond better to scheduled feedings and structured caregiving routines than to demand feedings and frequent changes in daily routines. These children sleep less and may need more structured approaches to bedtime to prevent bedtime problems. “Highly distractible” children may require additional soothing measures such as swinging, rocking, or being carried in a pack that the parent wears across the chest or back. Children with “high activity” levels require vigilant watching, and parents need to take extra precautions in safeguarding the home. These children benefit from increased opportunities for gross motor activity to constructively channel their energy.

The child who is “slow to warm up” may demonstrate more stranger fear than other children and may require gradual and frequent preparation for new situations, such as substitute child care. Even the “easy child” can present problems in that the parents may need reminders to feed the child who sleeps for prolonged intervals and rarely cries. They may need to “retrain” the child because of the ease of developing habits such as keeping the child up late or sleeping with the youngster, which may later become troublesome.

Appropriate counseling based on awareness of the child’s temperament can greatly enhance the quality of interaction between parents and infant. Even just letting parents know that “difficult” traits are innate can relieve feelings of guilt and incompetence.

Because of the complexity of the developmental process during the first 12 months, Table 10-2 is presented to help organize and clarify the data already discussed. Although all milestones are important, some represent essential integrative aspects of development that lay the foundation for achievement of more advanced skills. These essential milestones are designated by a square () in the table. The table represents the average monthly age at which various skills are attained. It must be remembered that, although the sequence is the same, the rate will vary among children.

Separation and Stranger Fear

A number of fears can appear during infancy. However, the fear that causes parents the most concern is fear related to strangers and separation. Although erroneously interpreted by some as a sign of undesirable, antisocial behavior, stranger fear and separation anxiety are important components of a strong, healthy parent-child attachment. Nevertheless, this period can present difficulties for the parent and child. Parents may be more confined to the home because the infant violently protests having baby-sitters. To accustom the infant to new people, parents are encouraged to have close friends or relatives visit often. This provides other persons with whom the child is comfortable and can give parents time for themselves.

Infants also need opportunities to safely experience strangers. Usually toward the end of the first year, infants begin to venture away from the parent and demonstrate curiosity about strangers. If allowed to explore at their own rate, many infants eventually “warm up.” If parents hold the child away from their face, the infant can observe while maintaining close physical contact.

The best approach for the stranger (including nurses) is to talk softly; meet the child at eye level (to appear smaller); maintain a safe distance from the infant; and avoid sudden, intrusive gestures, such as holding the arms out and smiling broadly.

Parents also may wonder whether they should encourage the child’s clinging, dependent behavior, especially if there is pressure from others who view this as “spoiling” (see following discussion). Parents need to be reassured that such behavior is healthy, desirable, and necessary for the child’s optimal emotional development. If parents can reassure the infant of their presence, the infant will learn to realize that they are still there even if not physically present. Talking to infants when leaving the room, allowing them to hear one’s voice on the telephone, and using transitional objects (e.g., a favorite blanket or toy) reassures them of the parent’s continued presence.

Alternate Child Care Arrangements

For many parents, especially working mothers, locating safe and competent child care facilities for the infant is an increasingly difficult problem—one that is compounded by the number of mothers working outside the home. Over the past 40 years there have been variable shifts in child care arrangements; whereas the majority of children are cared for in group centers or other settings, there are increasingly more children being cared for in home settings.

The basic types of care are in-home care, either in the parents’ or caregivers’ home (family daycare), and center-based care, usually in a daycare center. In-home care may consist of a full-time baby-sitter who lives in the home, a full-time baby-sitter who comes to the home, cooperative arrangements such as exchange baby-sitting, or family daycare. A licensed small family childcare home typically provides care and protection for up to six children for part of a 24-hour day and does not include informal arrangements such as exchange baby-sitting or caregivers in the child’s own home. The six children may include the family daycare provider’s own children younger than 5 years of age living in the home. Large family childcare homes may provide care for eight to twelve children. Unfortunately, many family daycare homes operate without a license and may care for large numbers of infants without adequate staff and facilities.

Child center-based care usually refers to a licensed daycare facility that provides care for six or more children, for 6 or more hours in a 24-hour day. Work-based group care is another option that is becoming increasingly popular as employers recognize the benefit of providing high-quality and convenient child care to their employees. Sick-child care may also be available for times when the youngster is ill. Such programs are often located in community hospitals or in work settings.

A major nursing responsibility is guiding parents in locating suitable facilities that have a well-qualified staff. State licensing agencies can help parents identify daycare centers that accept children of specific age-groups and are convenient to home and work. Their records are available to the public and provide reports from the health, safety, and fire departments; periodic evaluations from the licensing agency; complaints filed against the center; and qualification of the center’s employees. State-licensed programs are supposed to abide by established standards, which represent the minimum requirements and safeguards. However, enforcement of the standards is sometimes inadequate.

Early childhood programs may also belong to a voluntary accreditation system sponsored by National Association for the Education of Young Children, which serves as a model for optimum care.^* References from other parents are also helpful, provided that they have investigated the center carefully and have remained involved with the agency’s activities.

Guidelines for selecting child care facilities are discussed under Preschool and Kindergarten Experience, Chapter 13. The same conscientious attention should be applied to locating competent baby-sitters. References from other employers are essential, and there is no substitute for observing the interaction between the individual and the child. Although very young infants need little if any preparation for the introduction of a new caregiver, older infants may benefit from a gradual placement to reduce stranger anxiety. At all times the parent should have the right to visit the child, and regular conferences should be established to review the child’s progress.

One of the areas that is increasingly important in selecting child care is the center’s health practices; however, parents often do not check the center for health and safety features. Evidence shows that children, especially those under age 3 years in daycare centers, have more illnesses—especially diarrhea, otitis media, respiratory tract infections (especially if the caregiver smokes), hepatitis A, meningitis, and cytomegalovirus—than children cared for in their home. The strongest predictor of risk of illness is the number of unrelated children in the room. Proactive infection control measures and education of staff have been effective in reducing the incidence of upper respiratory tract infections, diarrhea, and rotavirus. It has been reported that families who have children in out-of-home child care lose an estimated 13 days of work per year as a result of infections (Brady, 2005). Parents should inquire about the center’s policy regarding the attendance and care of sick children.

Limit Setting and Discipline

As infants’ motor skills advance and mobility increases, parents are faced with the need to set safe limits to protect the child and establish a positive and supportive parent-child relationship (see Nurse’s Role in Injury Prevention, p. 372). Although there are numerous disciplinary techniques, some are more appropriate for this age than others. An effective approach used in disciplining a child is the use of time-out. The basic principles are the same as those discussed in Chapter 3, except that the place for time-out needs to be commensurate with the child’s abilities. For example, the playpen is better for most infants than a chair. Although parents may be concerned about instituting discipline during infancy, it is important to stress that the earlier effective disciplinary methods are employed, the easier it is to continue these approaches.

Parents must recognize the infant’s cognitive and behavioral limitations; adequate protection from hazards must be implemented because infants and toddlers do not understand a cause-and-effect relationship between dangerous objects and physical harm. Additionally, parents may need reassurance that their infant’s behavior is exploratory in nature, not oppositional (at this age) and primarily centered on the infant’s basic needs of warmth, love, food, security, and comfort. Parents may verbalize that comforting the infant too much or meeting its needs will result in a spoiled child; there is no substantial evidence that meeting the infant’s basic needs will result in such behaviors later in life. Children will innately test limits and explore during the exploratory phase of growth; instead of discouraging exploration, parents should provide safe alternatives, put dangerous household items away, and give children consistent discipline and nurturing.

Effective teaching for injury prevention optimally begins in infancy by helping parents understand the nature of their child’s normal development. It must be reiterated continually that infants cry because a need is not being met, not to intentionally irritate an adult. The fussy or irritable infant is a potential victim of shaken baby syndrome (or other bodily harm), since adults and caretakers may not understand the nature of the infant’s crying.

Thumb Sucking and Use of a Pacifier

Sucking is the infant’s chief pleasure and may not be entirely satisfied by breastfeeding or bottle feeding. It is such a strong need that infants who are deprived of sucking, such as those with a cleft lip repair, will suck on their tongue. Some newborns are born with sucking blisters on their hands from in utero sucking activity. The benefits of nonnutritive sucking in preterm infants include increased weight gain, decreased length of stay, and improved pain management (Pinelli and Symington, 2000; Pinelli, Symington, and Ciliska, 2002). There is currently no evidence that pacifier use and nonnutritive sucking in preterm infants has any effect on the initiation and length of breastfeeding. Nonnutritive sucking should not be withheld from preterm infants, especially when performed in conjunction with the use of concentrated sucrose for pain management.

Pacifier use, particularly in the early days after birth and in the birth hospital, has gained considerable attention in the scientific literature. Some experts now state that “nontherapeutic” pacifier use should be discouraged, since there are no known benefits to its use other than for nonnutritive sucking and for managing pain.

Biancuzzo (2003) suggests that it cannot be stated with absolute certainty that pacifier use is bad in every situation but warns there is potential harm in the use of pacifiers based on available evidence. Furthermore, she admonishes health care workers to be informed regarding potential harm in pacifier use and to inform parents of the potential. Lawrence and Lawrence (2005), as well as other experts in breastfeeding, recommend that health care workers not introduce pacifiers to breast-fed infants unless at the request of the parent. Pacifier use is not recommended as part of the Baby-Friendly Hospital Initiative. (See Box 8-5, p. 230.)

A review of studies by the Joanna Briggs Institute (2005) found an association between pacifier use in infancy and a reduction in breastfeeding and exclusive breastfeeding. However, the authors concluded that pacifier use did not cause a reduction in breastfeeding; rather it was a “marker for socioeconomic, demographic, psychosocial and cultural factors that determine pacifier use and breastfeeding.” In addition, the researchers examined studies related to pacifier use and prevention of SIDS; infants put to sleep with a pacifier had a reduced risk of SIDS. Because of the limited number of studies correlating pacifier use and increased risk of infections or dental malocclusion, the authors were unable to make any recommendations for or against pacifier use in relation to these practices (Joanna Briggs Institute, 2005).

The American Academy of Pediatrics (2005) recommends limited pacifier use in infants, citing the strong evidence for pacifier use and its protective effect in SIDS reduction; the exact mechanism involved in the protection for SIDS is not known. Still, pacifier use should not replace actual feeding or suckling; prohibiting pacifier use will not absolutely ensure an increase in the length of breastfeeding; and there should be an emphasis on allowing the infant to control the pace, frequency, and termination of feeding rather than allowing the pacifier (or anything else) to become the focus of the interaction.

To decrease dependence on nonnutritive sucking in young infants, sucking pleasure can be increased by prolonging feeding time. Also, the parent’s excessive use of the pacifier to calm the child should be explored. It is not unusual for parents to place a pacifier in the infant’s mouth as soon as crying begins, thus reinforcing a pattern of distress-relief.

The effect of continual pacifier use on early speech and language development is unknown, but the pacifier may decrease the child’s desire to imitate sounds and affect intelligibility. Parents need to be alerted that continual dependence on a pacifier may influence social and speech development.

If the child uses a pacifier, safety considerations in purchasing one must be stressed. Parents should be cautioned against altering a pacifier, thus making it more dangerous (see Aspiration of Foreign Objects, p. 365).

During infancy and early childhood there is no need to restrain nonnutritive sucking of the fingers. Malocclusion may occur if thumb sucking persists past 4 to 6 years of age, or when the permanent teeth erupt. Pacifiers may be perceived by some parents as less damaging because they are discarded by 2 to 3 years of age, whereas thumb sucking may persist well into school-age years. Both pacifier use and thumb sucking may also have significant cultural variations.

Thumb sucking reaches its peak at age 18 to 20 months and is most prevalent when the child is hungry, tired, or feeling insecure. Persistent thumb sucking in a listless, apathetic child always warrants investigation. It may be a sign of an emotional problem between parent and child or of boredom, isolation, and lack of stimulation.

Teething

One of the more difficult periods in the infant’s (and parents’) life is the eruption of the deciduous (primary) teeth, often referred to as teething. The age of tooth eruption shows considerable variation among children, but the order of their appearance is fairly regular and predictable (Fig. 10-10). The first primary teeth to erupt are the lower central incisors, which appear at approximately 6 to 10 months of age (average 8 months). These are followed closely by the upper central incisors.

Teething is a physiologic process; some discomfort is common as the crown of the tooth breaks through the periodontal membrane. Some children show minimum evidence of teething, such as drooling, swollen gums, increased finger sucking, or biting on hard objects. Others are very irritable, have difficulty sleeping, and refuse to eat. Generally, signs of illness such as fever, vomiting, or diarrhea are not symptoms of teething but of illness and may warrant further investigation (Macknin, Piedmonte, Jacobs, and others, 2000). Anderson (2004) suggests that frequent waking periods are related to environmental, behavioral, or developmental changes rather than teething. The author also cautions parents (and health care workers) to not overdiagnose teething; the ill-appearing child or child with a temperature over 38° C (100.4° F) should be evaluated by the practitioner.

Because teething pain is a result of inflammation, cold is soothing. Giving the child a frozen teething ring or an ice cube wrapped in a washcloth helps relieve the inflammation. Several nonprescription topical anesthetic ointments are available, such as Baby Ora-Jel, although parents and health care workers should be aware of the risks of using topical anesthetic products (absorption rates vary in infants) (Anderson, 2004). The active ingredient in most of them is benzocaine. If such products are used, parents are advised to apply them correctly. In the event of persistent irritability that affects sleeping and feeding, systemic analgesics such as acetaminophen or ibuprofen can be given (if age appropriate) for no more than 3 days (Anderson, 2004); however, parents should know that this is a temporary measure and should contact the practitioner if symptoms persist or if the child’s condition changes.

Infant Shoes

Many parents are unaware of the types of shoes that are appropriate for the older infant and buy expensive infant shoes because of misleading advertising claims. Inflexible shoes that have hard soles can be detrimental by delaying walking, aggravating intoeing or outtoeing, and impeding the development of supportive foot muscles. Therefore counseling parents regarding footwear should begin when infants are 6 months old—well before they are walking.

It is helpful to begin by explaining to parents that changes in the feet occur during infancy and early childhood as locomotion and weight bearing progress. At birth the feet are flat because the arches are protected by fat pads on the soles. As the bones in the arches develop, the pads disappear and the feet begin to assume a mature shape. A normal arch is determined by proper alignment of all the bones and development of the surrounding musculature, not by the height of the arch.

When children begin walking, the main reason for shoes is protection. To provide protection, the shoe should retain its fit; be made of durable material with a smooth interior and few construction seams to irritate the skin; and be soft and flexible, especially in the toe area. A high-top shoe is not necessary for support but may be helpful in keeping the foot in the shoe. A good infant-toddler shoe is one that can easily be bent in half by squeezing the heel and toe with the thumb and index finger (Wall, 2000).

A good shoe conforms to the anatomic shape of the foot, with a rounded toe and sufficient toe room. During weight bearing there should be the space of at least half the width of the thumbnail, or 1.25 cm (0.5 inch), between the end of the longest toe and the shoe. Roomy and square-toed socks allow for proper growth and alignment. Inexpensive but well-constructed athletic shoes or soft-leather moccasin-type shoes are suggested as adequate footgear for walking infants.

Even if the shoes are fitted properly, frequent changes are needed to accommodate the infant’s rapidly growing feet. Shoe size changes at approximately 3-month intervals between 12 and 36 months; during this time the child’s foot should be measured every 3 months. Curled toes when shoes are removed and redness and irritation of the skin on the bottom of the toes indicate the need for a larger size.

The First 6 Months

Human milk is the most desirable complete diet for the infant during the first 6 months. The normal infant receiving breast milk from a well-nourished mother usually requires no specific vitamin or mineral supplements, with a few exceptions. The American Academy of Pediatrics (2003) recommends that all infants (including those exclusively breast-fed) receive a daily supplement of 200 IU of vitamin D beginning in the first 2 months of life to prevent rickets and vitamin D deficiency. If the infant is being exclusively breast-fed after 4 to 6 months (when fetal iron stores are depleted), iron supplementation, which may be accomplished with iron-fortified cereal, is recommended to offset the decrease in iron available in human milk at this time and to enhance erythropoiesis. Infants who are breast-fed or bottle-fed do not require additional fluids, especially water or juice, during the first 4 months of life. Excessive intake of water in infants may result in water intoxication, failure to thrive, and hyponatremia.

Employed mothers can continue breastfeeding with guidance and encouragement. Mothers are encouraged to set realistic goals for employment and breastfeeding, with accurate information regarding the costs, risks, and benefits of available feeding options. Barriers encountered by working breastfeeding mothers include lack of employer or co-worker support, unavailable or inadequate facilities for pumping and storing milk, and insufficient time allowed to pump during work (Rojjanasrirat, 2004). Important themes that emerged in the study by Rojjanasrirat (2004) of working breastfeeding mothers included support (emotional, informational, and instrumental), attitude, and psychologic distress.

Many mothers may find that a program of breast pumping when away from home and bottle feeding the infant the expressed milk with or without formula supplementation is successful. Expressed breast milk may be stored in the refrigerator (4° C [39° F]) without danger of bacterial contamination for up to 5 days (Lawrence and Lawrence, 2005). Although feeding the infant at home may occur on a demand basis, pumping milk away from home may be needed every 3 to 4 hours to maintain adequate supply. Breast milk may be expressed by hand or pump (manual or electric) and stored in an appropriate air-tight glass or plastic container. Expressed breast milk may be frozen (−18° C [0° F] or lower) for up to 12 months (depending on the type of freezer used), but care should be taken to prevent freezer burn (see Appendix P, protocol no. 8, in Lawrence and Lawrence, 2005, for further guidelines on storing and freezing human milk). Health care workers and new mothers may find the booklet “Working and Breastfeeding—Can You Do It? Yes, You Can!” (available in English and Spanish) by Johnson & Johnson helpful.^*

In addition to efficient breast pumping, mothers also need child care by a trusted individual or agency and support and assistance from significant others. As with all breastfeeding mothers, these women must have proper nutrition and rest for adequate lactation. Maternal fatigue is considered the biggest threat to successful breastfeeding in employed mothers.

An acceptable alternative to breastfeeding is commercial iron-fortified formula. Like human milk, it supplies all nutrients needed by the infant for the first 6 months. Unmodified whole cow’s milk, low-fat cow’s milk, skim milk, other animal milks, and imitation milks are not acceptable as a major source of nutrition for infants because of their limited digestibility, increased risk of contamination, and lack of components needed for appropriate growth. Whole milk can cause iron deficiency anemia in infants, possibly as a result of occult gastrointestinal blood loss. Pasteurized whole cow’s milk is deficient in iron, zinc, and vitamin C and has a high renal solute load, which makes it undesirable for infants less than 12 months of age (American Academy of Pediatrics, 2004).

The amount of formula per feeding and the number of feedings per day vary among infants. Infants being fed on demand usually determine their own feeding schedule, but some infants may need a more planned schedule based on average feeding patterns to ensure sufficient nutrients. In general, the number of feedings decreases from six at 1 month of age to four or five at 6 months. Regardless of the number of feedings, the total amount of formula ingested will usually level off at about 32 ounces (946 ml) per day. Water supplementation is not recommended for healthy infants because it may lead to water intoxication (American Academy of Pediatrics, 2004).

The addition of solid foods before 4 to 6 months of age is not recommended. During the early months solid foods are not compatible with the ability of the gastrointestinal tract and infant’s nutritional needs. Feeding solids to young infants exposes them to food antigens that may produce food protein allergy. There is now ample evidence that early introduction of foods other than maternal milk in the first 6 months of life predisposes children to an increased risk for food allergy development; foods known to be allergenic (e.g., peanuts, eggs, fish, seafood) should be introduced later than 12 months according to the child’s risk for atopy (Fiocchi, Assa’ad, Bahna, and others, 2006).

Developmentally, infants are not ready for solid food. The extrusion (protrusion) reflex is strong and often causes them to push food out of the mouth. Infants instinctively suck when given food. Because of their limited motor abilities, infants are unable to deliberately push food away or avoid feeding. Therefore early introduction of solids is a type of forced feeding that may lead to excessive weight gain and increased predisposition to allergies and iron deficiency anemia. Parents should be cautioned concerning the excessive use of juices and nonnutritive drinks such as fruit-flavored drinks or carbonated beverages (soda or pop) during this period. Many juices and nonnutritive drinks, although readily available to consumers, do not provide sufficient and appropriate caloric intake for infants less than 12 months of age; such drinks may replace the nutrients in breast milk or formula and lead to growth or health problems. Fruit juices are not required in the first 6 months; there are no studies demonstrating benefits of giving fruit juice to infants.

The Second 6 Months

During the second half of the first year, human milk or formula should optimally continue to be the primary source of nutrition. Fluoride supplementation should begin, depending on the infant’s intake of fluoride (in formula mixed with tap water or bottled water [containing fluoride] as appropriate) (see Dental Health, p. 349). If breastfeeding is discontinued, a commercial iron-fortified formula should be substituted. Follow-up or transition formulas marketed for older infants offer no special advantages over other infant formulas and provide excessive protein (American Academy of Pediatrics, 2004).

The major change in feeding habits is the addition of solid foods to the infant’s diet. Physiologically and developmentally, the infant 4 to 6 months of age is in a transition period. By this time the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic foods. Tooth eruption is beginning and facilitates biting and chewing. The extrusion reflex has disappeared, and swallowing is more coordinated to allow the infant to accept solids easily. Head control is well developed, which permits infants to sit with support and purposely turn the head away to communicate lack of interest in food. Voluntary grasping and improved eye-hand coordination gradually allow infants to pick up finger foods and feed themselves. Their increasing sense of independence is evident in their desire to hold the bottle and try to “help” during feeding.

Selection and Preparation of Solid Foods

The choice of solid foods to introduce first is variable but should meet the reasons for feeding solids, such as supplying nutrients not found in formula or breast milk. Iron-fortified infant cereal is generally introduced first because of its high iron content (7 mg/3 Tbsp of prepared dry cereal). Commercially prepared ready-to-serve dry cereals for infants include rice, barley, oatmeal, and high-protein cereals; rice is usually suggested as an initial food because of its easy digestibility and low allergenic potential. Cereals such as cream of farina are not used, since infant commercial cereals are a better source of iron. Some of the commercial baby cereals are combined with fruit. There is little nutritional benefit from these preparations, and they are more expensive. New foods should be added one at a time; therefore parents should avoid cereal combinations when beginning a new grain.

Infant cereal (iron fortified) may be mixed with expressed breast milk or water until whole milk is given. After 6 months of age, small amounts of fruit juices can be mixed with the dry cereal; the vitamin C content of the juice enhances the absorption of iron in the cereal. Because of their benefit as a source of iron, infant cereals should be continued until the child is 18 months of age.

Fruit juice can be offered from a cup for its rich source of vitamin C and as a substitute for milk for one feeding a day. Large quantities of certain juices (e.g., apple, pear, prune, sweet cherry, peach, grape) are avoided because they may cause abdominal pain, diarrhea, or bloating in some children. Avoid fruit-flavored drinks, which may be marketed as juices but contain high concentrations of complex sugars. White grape juice (no more than 5 oz/day) is reported to be better absorbed and safe for infants this age without causing gastrointestinal distress (Calamaro, 2000). Some researchers have found fruit juice, particularly apple juice, to exacerbate colic and diarrhea, possibly because of carbohydrate malabsorption (Duro, Rising, Cedillo, and others, 2002; Moukarzel, Lesicka, and Ament, 2002). The American Academy of Pediatrics (2001b, 2006a) recommends that fruit juice intake not exceed 4 to 6 ounces per day and that juices not be given to infants less than 4 to 6 months old. Because vitamin C is naturally destroyed by heat, juice is not warmed. Juice containers are always kept covered and refrigerated to prevent further vitamin loss.

The addition of other foods is arbitrary. A common sequence is to introduce strained fruits followed by vegetables and, finally, meats; however, some clinicians prefer to add vegetables before fruit. If foods are introduced early, citrus fruits, meats, and eggs are delayed until after 6 months of age because of their potential to result in allergy. At 6 months, foods such as a cracker or zwieback can be offered as finger and teething foods. By 8 to 9 months, junior foods and nutritious finger foods such as firmly cooked vegetable, raw pieces of fruit, or cheese can be given. By 1 year, well-cooked table foods are served.

The introduction of solid foods into the infant’s diet at this age is primarily for taste and chewing experience. The majority of the infant’s caloric needs are derived from the primary milk source (human or formula); therefore solids should not be perceived as a substitute for milk until the child is older than 12 months. Portion sizes may vary according to the infant’s taste. In general, 1 tablespoon per year of age (i.e., ½ to ¾ tablespoon for most infants under 12 months) is adequate for most infants. In most cases 2 tablespoons may be served, but because of the infant’s focus on the texture and feel of the food, smaller amounts will be consumed. Another reason for smaller portions is the concern over feeding habits in early childhood and obesity; early feeding of smaller portions may help prevent the “clean your plate” or “eat all your food or you can’t get down from the table” concepts, which are known to contribute to overeating in later life. The addition of solid foods to the exclusively breast-fed infant’s diet does not significantly increase overall caloric intake or weight gain (Dewey, 2001).

Commercially prepared baby foods are the most common type of food served to infants in the United States. They are convenient but sometimes contain added salt or sugar and can be relatively expensive. An alternative is to prepare baby foods at home, which is a simple and inexpensive process. Fruits and vegetables can be steamed in a small amount of water and pureed in a blender or food processor. Many of them, such as ripe banana, can be mashed fine with a fork. Fruits such as apples or pears require little or no water in the cooking process. Vegetables such as carrots, potatoes, or string beans require additional water in the cooking and blending process.

Parents are cautioned to avoid reliance on foods and supplements marketed as iron- or vitamin-fortified as primary sources of minerals. Instead encourage parents to offer the child a variety of fruits, vegetables, and whole grains, including those known to naturally be rich in iron (Fox, Reidy, Novak, and others, 2006).

Introduction of Solid Foods

When the spoon is first introduced, infants often push it away and appear dissatisfied. Some patience and skill are required to overcome this initial response. Food that is placed on the front of the tongue and pushed out is simply scooped up and refed. As infants become accustomed to the spoon, they will more eagerly accept the food and eventually open the mouth in anticipation (or keep it closed in dislike). Because the first introduction of food is a new experience, spoon feeding should be attempted after ingestion of some breast milk or formula to associate this activity with a pleasurable and satisfying experience. Trying to introduce a food after the entire milk feeding is generally useless because the infant is satiated and has no inclination to try something new.

After several spoon feedings, food can be introduced at the beginning of a meal. It is best to introduce many foods during the first year, when the infant is more likely to eat them because of a hearty appetite resulting from a rapid growth rate. During the toddler years eating becomes less of an adventure, and strong food preferences emerge.

One food item is introduced at intervals of 4 to 7 days to allow for identification of food allergies. New foods are fed in small amounts, from 1 teaspoon to a few tablespoons. As the amount of solid food increases, the quantity of milk is decreased to less than 1 L/day to prevent overfeeding.

Because feeding is a learning process, as well as a means of nutrition, new foods are given alone to allow the child to learn new tastes and textures. Food should not be mixed in the bottle and fed through a nipple with a large hole. This deprives the child of the pleasure of learning new tastes and developing a discriminating palate. It can also cause problems with poor chewing of food later in life because of lack of experience. Guidelines for the introduction of new foods are given in the Family-Centered Care box.

Introducing solid foods can be an exciting time for parent and child. Most infants are good eaters and enjoy eating from a spoon and later feeding themselves. However, the transition from “parent doing it” to “baby doing it” can be a trying experience, particularly for those who value a clean house or who view cleaning up the mess as a waste of time. Finger foods such as soft fruits or vegetables are just as good as playthings as food; they can be squeezed, smeared, squashed, and thoroughly painted on oneself, others, and the environment. However, all of this is part of learning, and mastery follows many accidents.

Weaning

Defined as the process of giving up one method of feeding for another, weaning usually refers to relinquishing the breast or bottle for a cup. In Western societies this is generally regarded as a major task for infants and is often seen as a potentially traumatic experience. It is psychologically significant because the infant is required to give up a major source of oral pleasure and gratification.

There is no one time for weaning that is best for every child, but generally most infants show signs of readiness during the second half of the first year. They have learned that good things come from a spoon. It is recommended that weaning be accomplished with the infant’s needs as a guide (Lawrence and Lawrence, 2005). Their increasing desire for freedom of movement may lessen their desire to be held close for feedings. They are acquiring more control over their actions and can easily manipulate a cup to their lips (even if it is held upside down!). Imitation becomes a powerful motivator by age 8 or 9 months, and they enjoy using a cup or glass like others do.

Weaning should be gradual by replacing one bottle or breastfeeding session at a time. The nighttime feeding is usually the last feeding to be discontinued. It is advisable to never allow a child to take a bottle of milk to bed—this is a major cause of nursing caries in deciduous teeth. If breastfeeding is terminated before 5 or 6 months of age, weaning should be to a bottle to provide for the infant’s continued sucking needs. If discontinued later, weaning can be directly to a cup, especially by age 12 to 14 months. Any sweet liquid, such as fruit juice, should be given in a cup, and not at bedtime.

Sleep Problems

A number of sleep problems are identified in small children. The two major categories are the dyssomnias: the child has trouble either falling or staying asleep at night, or has difficulty staying awake during the day. The second category, parasomnias, are characterized as confusional arousals, sleep-walking, sleep terrors, nightmares, and rhythmic movement disorders; these typically occur in children 3 to 8 years old (Dahl, 1998) and decline in incidence as the child matures (Davis, Parker, and Montgomery, 2004). This discussion focuses on minor sleep issues in infants such as refusal to go to sleep or frequent waking during the night (Table 10-3). Other sleep disturbances such as obstructive sleep apnea and sleep terrors are discussed elsewhere in this text.

Concerns regarding sleep are common during infancy (see Cultural Awareness box). Sometimes these concerns are as basic as parents’ questioning whether the infant needs additional sleep. In this case it is best to investigate the reason for their concern, stressing the individual needs of each child. Infants who are active during wakeful periods and growing normally are sleeping a sufficient amount of time.

Sleep problems in early infancy have also been positively correlated with higher maternal depression scores (Hiscock and Wake, 2001; Hawkins-Walsh, 2003) and poorer general and mental health in both mother and father (Martin, Hiscock, Hardy, and others, 2007); therefore nurses must discuss infant sleep problems with the mother (and family) in addition to other developmental aspects of newborn care.

When a sleeping problem is presented, a careful assessment is essential. Charting sleep habits both before and after interventions is also an important strategy. Questions regarding the frequency and duration of waking, the usual bedtime routine, the number of nighttime feedings, the perceived problem (e.g., how much disruption the behavior generates), and the attempted interventions are important in planning effective approaches designed for the specific sleep problem. A common suggestion given for any type of sleep problem, “Let the child cry until he or she falls asleep,” is very difficult to implement and is inappropriate for certain conditions. After the parents relent and console the child, they have only reinforced the crying.

Another approach to night crying is known as graduated extinction . This involves letting the child cry for progressively longer times between brief parental interventions that consist only of reassurance—not rocking, holding, or using a bottle or pacifier. For example, the parents may check on the child every 5 minutes (of crying) during the first night and progressively extend this interval by 5 minutes on successive nights (Ferber and Kryger, 1995).

Families who cannot tolerate unexpected crying spells while everyone else is asleep can try the two-step approach. Graduated extinction is used during naps and at bedtime until the parents retire. If the child cries during the night, the parents use comforting measures. However, after the child is partially trained, step 2 is initiated—the use of graduated extinction at all times.

Children who learn to fall asleep on their own at bedtime have longer sustained sleep periods than those who fall asleep with a parent present (Davis, Parker, and Montgomery, 2004). In addition, comforting children outside their own bed at night once they awaken was associated with poor sleep consolidation. Feeding the 5-month-old after awakening at night has been associated with fewer consecutive sleep hours (Touchette, Petit, Paquet, and others, 2005). The authors of this study recommend parental presence at bedtime until the child is drowsy, then placing the child in his or her own bed for a night’s sleep.

The best way to prevent sleep problems is to encourage parents to establish bedtime rituals that do not foster problematic patterns. One of the most constructive is placing infants awake in their own crib. When infants are accustomed to falling asleep somewhere else, such as in their parent’s arms, and then being transferred to their crib, they awaken in unfamiliar surroundings and are unable to fall asleep until the routine is repeated. Also, the bed should be used for sleeping only—not as a playpen. It is advisable not to hang playthings over or on the bed; in this way the child associates the bed with sleep, not with activity. Although the interventions described previously and in Table 10-3 are usually successful, it is much easier to prevent the problem with appropriate counseling during the early months of the infant’s life.

Schedule for Immunizations

In the United States two organizations—the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the Committee on Infectious Diseases of the American Academy of Pediatrics—govern the recommendations for immunization policies and procedures. In Canada, recommendations are from the National Advisory Committee on Immunization under the authority of the minister of health and Public Health Agency of Canada. The policies of each committee are recommendations, not rules, and they change as a result of advances in the field of immunology. Nurses need to keep informed of the latest advances and changes in policy (see Community Focus box).

In the United States the recommended age for beginning primary immunizations of infants is within 2 weeks of birth or, in special circumstances, at birth (Fig. 10-11, A). Infants born preterm should receive the full dose of each vaccine at the appropriate chronologic age. Recommended schedules for children not immunized during infancy are included in Fig. 10-12. Table 10-4 describes Canadian immunization schedules for children.

Children who began primary immunizations at the recommended age but fail to receive all of the doses do not need to begin the series again but instead receive only the missed doses. For situations in which there is doubt that the child will return for immunizations according to the optimum schedule, any of the recommended vaccines can be administered simultaneously. Parenteral vaccines are given in separate syringes in different injection sites (American Academy of Pediatrics, 2006b). The product brand names, routes of administration, and manufacturers for the principal childhood vaccinations are listed in Table 10-7.

Recommendations for Routine Immunizations

Hepatitis A Virus (HAV). HAV has been recognized as a significant child health problem, particularly in communities where widespread childhood hepatitis A immunization is not recommended. HAV is spread by the fecal-oral route and from person-to-person contact, by ingestion of contaminated food or water, and rarely by blood transfusion. The illness has an abrupt onset, with fever, malaise, anorexia, nausea, abdominal discomfort, dark urine, and jaundice being the most common clinical signs of infection. In children under 6 years of age the disease may be asymptomatic, and jaundice is rarely evident.

HAV vaccine is now recommended for all children beginning at age 1 year (i.e., 12 months to 23 months); the second dose in the two-dose series may be administered no sooner than 6 months after the first dose. Since the implementation of widespread childhood HepA vaccination, infection rates among children ages 5 to 14 years have declined significantly (Centers for Disease Control and Prevention, 2006a). For further information see footnote 9 in Fig. 10-11, A.