Parents commonly have multiple concerns during normal infant growth and development. Although most of these issues are not actual disease states or behavior problems, nurses must be aware of these issues to recognize them and to intervene appropriately.
Colic
Healthy 6-week-old infants cry for a total of about 3 hours every day. Crying and fussing are more prevalent in the evenings. By age 12 weeks, the total amount of crying is about 1 hour per day, and infants are better able to soothe themselves by this age. Colic is defined as inconsolable crying that lasts 3 hours or longer per day and for which there is no physical cause. It typically resolves by 3 months of age, coinciding with the age at which infants are better able to soothe themselves (e.g., by finger sucking). The cause of colic is thought to be problems in the gastrointestinal or neurologic system (probably system immaturity), temperament, or parenting style of the mother or father. Some parents are overly anxious or overly attentive or, at the other extreme, may not give the infant the attention he or she needs. Any of these may contribute to a baby’s fussing and crying.
Prolonged crying leads to increased stress among caregivers. Failure to stop the crying leads to frustration, and crying that prevents the parents from sleeping contributes to the exhaustion they are already experiencing.
Educate parents that normal crying increases by the time the infant is 6 weeks old and diminishes by about 12 weeks. When faced with a colicky baby, parents should develop a stepwise approach to checking that all of the infant’s basic needs are met. When these needs are met, attempts at soothing the infant may be used. Reducing stimulation may decrease the length of crying. Carrying the infant more may also be helpful. Some infants respond to the motion of an infant swing or a car ride. Vibration, white noise, or swaddling
may also help to decrease fussing in some infants. Pacifiers can be soothing to babies who need additional nonnutritive sucking.
Parents should try one intervention at a time, taking care not to stimulate the infant excessively in the process of searching for solutions. Nurses should provide ongoing support to the parents of a colicky infant and reassure them that this is a temporary condition that will resolve in time (Shelov & Altmann, 2009).
Spitting Up
Spitting up (regurgitating small amounts of stomach contents) occurs in all infants, and a significant number of normal infants spit up excessively. Although spitting up after feeding is normal, it can be a cause of great concern to parents. Overfed babies who feed based on a parent-designed schedule and those who burp poorly are more likely to spit up. For some infants, the amount and frequency of spitting up are significant, and it may indicate gastroesophageal reflux.
Teach parents that feeding smaller amounts on a more frequent basis may help to decrease spitting-up episodes. Always burp the baby at least two or three times per feeding. Keep the baby upright for 30 minutes after feeding and do not lay the infant prone after feeding. Avoid bouncing or excess activity immediately after feeding. Positioning in an infant seat compresses the stomach and is not recommended. When placing the baby in bed, position him or her on the side with the head of the bed slightly elevated (Shelov &
Altmann, 2009).
EVIDENCE-BASED PRACTICE 3.1 BENEFITS AND RISKS OF PACIFIER USE
STUDY
The authors review the history of pacifier use and several recent research studies that attempted to determine the risks and benefits of pacifier use. The majority of the studies were performed within the early part of the 21st century.
Findings
Upon analysis of the various research studies, the authors reached several conclusions. Pacifier use has been shown to lower the risk of sudden infant death syndrome (SIDS) when used at the time of sleep. Additional benefits include assistance in development of neurologic maturity in pre-term infants and not shortening breastfeeding duration in preterm or term infants older than 1 month of age. Potential risks include shortening of breastfeeding duration if a pacifier is used before 1 month of age, increased incidence of otitis media when used after 1 year of age, and development of dental misalignment.
Nursing Implications
In light of the potential risks and benefits of pacifier use, nurses must be prepared to provide parents with accurate information related to the use of pacifiers. Educate parents to avoid introduction of the pacifier until breastfeeding is well established (4 weeks of age), to use pacifiers only during periods of sleep, and to never force a pacifier on an infant or replace a pacifier in a sleeping infant’s mouth. Additionally, parents should begin to wean the infant from the pacifier in late infancy so that it is not used past 1 year of age.
Adapted from M arter, A., & Agruss, J. C. (2007). Pacifiers: An update on use and misuse. Journal for Specialists in Pediatric Nursing, 12(4), 278-285.
Reassure parents that if the infant is wetting at least six diapers per 24 hours and gaining weight, the spitting up is normal. If the infant vomits one third or more of most feedings, chokes when vomiting, or experiences forceful emesis, the primary care provider should be notified.
Thumb Sucking, Pacifiers, and Security Items
Infants demonstrate a clear need for nonnutritive sucking: even fetuses can be observed sucking their thumbs or fingers in utero.
Thumb sucking is a healthy self-comforting activity. Infants who suck their thumbs or pacifiers often are better able to soothe themselves than those who do not. Studies have not shown that sucking either thumbs or pacifiers leads to the need for orthodontic braces unless the sucking continues well beyond the early school-age period. However, pacifier use has been associated with the increased incidence of otitis media, and hygiene is always a concern as pacifiers often fall on the floor (Marter & Agruss, 2007).
Infants may also become attached to a doll, stuffed animal, or blanket. Just like thumb sucking, the attachment item gives the infant the security to self-soothe when he or she is uncomfortable.
Families need to explore their feelings and cultural preferences about sucking habits and security items. Parents should not try to break the habit during a stressful time for the infant. When the infant is intensely trying to master a new skill such as sitting or walking,
he or she may need the sucking or security item to self-soothe. Pacifiers and security items can be physically taken away at some point, but the thumb is attached. The infant who has become attached to thumb sucking should not have additional attention drawn to the issue, as that may prolong thumb sucking.
Families of infants who use pacifiers may want to wean the infant from the pacifier when the child approaches 1 year of age (Marter & Agruss, 2007). This is the time when the need for additional sucking naturally decreases. Attempts to wean the child from a security blanket or toy should probably be reserved for after infancy (see Evidence-Based Practice 3.1).
Teething
Discomfort is common as the tooth breaks through the periodontal membrane. Infants may drool, bite on hard objects, or increase finger sucking. Some infants may become very irritable, refuse to eat, and not sleep well. Fever, vomiting, and diarrhea are generally not considered a sign of teething but rather of illness.
Teething pain results from inflammation. Teach parents that application of cold may be soothing to the gums. The infant may chew on a cold teething ring, or parents can rub an ice cube wrapped in a washcloth on the gums. Over-the-counter topical anesthetics such as baby Orajel may also be helpful. Parents should apply the ointment correctly to the gums, avoiding the lips, as these ointments cause numbing. Occasionally, oral acetaminophen or ibuprofen may be given to relieve pain (Tinanoff, 2007).
Refer back to 6-month-old Allison Johnson. List some common developmental concerns of 6-month-old infants. What anticipatory guidance related to these concerns would you provide to her parents?
KEY CONCEPTS
Infancy encompasses the period from birth to age 12 months.
The infant exhibits tremendous growth, doubling the birthweight by 6 months of age and tripling it by 12 months of age.
Most organ systems are immature at birth and develop and mature over the first year of life.
Child development is orderly, sequential, and predictable, progressing in a cephalocaudal and proximodistal fashion.
The infant is mastering the psychosocial task of Trust versus Mistrust.
Cognitive development in infancy is sensorimotor; infants use their senses and progressing motor skills to master their environment.
The 12-month-old babbles expressively and uses two or three words with meaning.
Promotion of safety is of key importance throughout infancy.
Breastfeeding is the natural and preferred method for infant feeding.
Breastfed and bottle-fed infants should both be fed on cue rather than on a parent-designed schedule.
Solid foods should be introduced at age 4 to 6 months. A spoon should be used to feed the infant, and rice cereal should be the first food. New foods should be introduced no more frequently than every 4 to 7 days.
The cup may be introduced at 6 months of age. No-spill sippy cups are generally not recommended.
Spitting up and colic are parts of normal development in the otherwise thriving infant and do not require medical intervention.
REFERENCES
Abell, S., & Ey, J. L. (2007). Ask Dr. Sue. Bilingual child. Clinical Pediatrics, 46(7), 658-659.
American Academy of Pediatrics. (2004). Guidance for effective discipline. Retrieved March 4, 2011, from http://aappolicy.aappublications.org/cgi/content/full/pediatrics;101/4/723
American Academy of Pediatrics. (2005). Breastfeeding and the use of human milk. Pediatrics, 115, 496—506.
American Academy of Pediatrics. (2007). Policy statement: The use and misuse of fruit juice in pediatrics. Retrieved March 4, 2011, from http://aappolicy.aappublications.org/cgi/content/full/pediatrics:107/5/1210
American Academy of Pediatrics. (2010a). Car safety seats: Information for families 2010. Retrieved March 4, 2011, from http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats-Information-for-Families-2010.aspx American Academy of Pediatrics. (2010b). Safety for your child: Birth to 6 months. Retrieved March 4, 2011, from
http://www.healthychildren.org/English/tips-tools/Pages/Safety-for-Your-Child-Birth-to-6-Months.aspx
American Academy of Pediatrics. (2010c). Safety for your child: 6 to 12 months. Retrieved March 4, 2011, from http://www.healthychildren.org/English/tips-tools/Pages/Safety-for-Your-Child-6-to-12-Months.aspx
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. (2010). Prevention of drowning.
Pediatrics, 126, 178—185.
American Academy of Pediatrics, Committee on Nutrition. (2010e). Iron fortification of infant formulas. Retrieved March 4, 2011, from http://aappolicy.aappublications.org/cgi/content/full/pediatrics;104/1/119
Anderson, J. (2008). Discipline techniques for the 9 month old. Contemporary Pediatrics, 25 (6), 47—53, 55.
Baker, R. D., Greer, F. R., & the Committee on Nutrition. (2010). Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0—3 years of age). Pediatrics, 126, 1040—1050.
Brazelton, T. B., & Nugent, J. K. (1995). Neonatal behavioral assessment scale (3rd ed.). London: MacKeith Press.
Brown, J. (2011). Nutrition now (6th ed.). Florence, KY: Wadsworth Publishing.
Carpenito-Moyet, L. J. (2010). Nursing diagnosis: Application to clinicalpractice (13th ed.). Philadelphia: Lippincott Williams &
Wilkins.
Centers for Disease Control and Prevention. (2010). Breastfeeding report card - United States, 2010. Retrieved March 4, 2011, from http://www.cdc.gov/breastfeeding/pdf/BreastfeedingReportCard2010.pdf
Child Development Institute. (2010). Temperament and your child’s personality. Retrieved June 16, 2011, from http://www.childdevelopmentinfo.com/development/temperament_and_your_child.htm
Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: W. W. Norton and Company.
Feigelman, S. (2007). The first year. In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (18th ed.). Philadelphia: Saunders.
Feigin, R. D., Cherry, J., Kaplan, S. L., & Demmler-Harrison, G. J. (2009). Feigin and Cherry’s textbook of pediatric infectious disease (6th ed.). Philadelphia: Saunders.
Ferry, R. J. (2010). Short stature. Retrieved June 16, 2011, from http://emedicine.medscape.com/article/924411-overview
Glader, B. E. (2007). Physiologic anemia of infancy. In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (18th ed.). Philadelphia: Saunders.
Goldson, E., & Reynolds, A. (2011). Child development and behavior. In W. W. Hay, M. J. Levin, J. M. Sondheimer, & R. R.
Deterding (Eds.), Current pediatric diagnosis and treatment (20th ed.). New York: McGraw-Hill.
Greenbaum, L. A. (2007). Electrolyte and acid-base disorders. In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (18th ed.). Philadelphia: Saunders.
Hagan, J. F., Shaw, J. S., & Duncan, P. (2008). Bright futures guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics.
Heird, W. C. (2007). The feeding of infants and young children. In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (18th ed.). Philadelphia: Saunders.
Johns Hopkins Hospital, Custer, J. W., Rau, R. E., & Lee, C. K. (2008). The Harriett Lane handbook (18th ed.). St. Louis:
Mosby.
Leininger, M. M., & MacFarland, M. R. (2006). Culture, care, diversity and universality: A worldwide nursing theory (2nd ed.). Sudbury, MA: Jones & Bartlett.
Marter, A., & Agruss, J. C. (2007). Pacifiers: An update on use and misuse. Journal for Specialists in Pediatric Nursing, 12 (4), 278—285.
National Association of Pediatric Nurse Practitioners. (2007). NAPNAP position statement on breastfeeding. Journal of Pediatric Health Care, 21, 39A—40A.
National Association of Pediatric Nurse Practitioners. (2011a). Successful bottlefeeding. Retrieved March 4, 2011, from http://www.napnap.org/Files/bottle_eng.pdf
National Association of Pediatric Nurse Practitioners. (2011b). The scoop on babies’ poop. Retrieved March 4, 2011, from http://www.napnap.org/Files/poop_eng.pdf
Piaget, J. (1969). The theory of stages in cognitive development. New York: McGraw-Hill.
Rozier, R. G. (2010). Evidence-based clinical recommendations on the prescription of dietary fluoride supplements for caries prevention. Journal of the American Dental Association, 141 (12), 1480—1489.
Rychnovsky, J. D. (2000). No-spill sippy cups. Journal of Pediatric Health Care, 14 (5), 207—208.
Safe Kids Worldwide. (2009). Crib safety. Retrieved March 4, 2011, from http://www.safekids.org/safety-basics/safety- guide/baby-safety-basics/crib-safety.html
Schuman, A. T. (2007). The ABCs of toy safety: More than just child’s play. Contemporary Pediatrics, 24 (7), 49—57, 64.
Shelov, S. P., & Altmann, T. R. (Eds.). (2009). Caring for your baby and young child: Birth to age 5 (5th ed.). New York:
Bantam Books.
Tinanoff, N. (2007). Periodontal diseases. In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (18th ed.). Philadelphia: Saunders.
U.S. Department of Health and Human Services. (2011). Healthy people 2020. Retrieved March 4, 2011, from http://www.healthypeople.gov/2020/default.aspx
Wyllie, R. (2007). Normal development, structure, and function. In Kliegman, R. M., Behrman, R. E., Jenson, H. B., & Stanton, B.
(Eds.). Nelson textbook of pediatrics (18th ed.). Philadelphia: Saunders.
Zuckerman, B. (2009). Promoting early literacy in pediatric practice: Twenty years of Reach Out and Read. Pediatrics, 124, 1660
—1665.
CHAPTER WORKSHEET
MULTIPLE CHOICE QUESTIONS
1. The mother of a 3-month-old boy asks the nurse about starting solid foods. What is the most appropriate response by the nurse?
a. “It’s okay to start pureed solids at this age if fed via the bottle.”
b. “Infants don’t require solid food until 12 months of age.”
c. “Solid foods should be delayed until age 6 months, when the infant can handle a spoon on his own.”
d. “The tongue extrusion reflex disappears at age 4 to 6 months, making it a good time to start solid foods.”
2. The father of a 2-month-old girl is expressing concern that his infant may be getting spoiled. The nurse’s best response is:
a. “She just needs love and attention. Don’t worry; she’s too young to spoil.”
b. “Consistently meeting the infant’s needs helps promote a sense of trust.”
c. “Infants need to be fed and cleaned; if you’re sure those needs are met, just let her cry.”
d. “Consistency in meeting needs is important, but you’re right, holding her too much will spoil her.”
3. Parents of an 8-month-old girl express concern that she cries when left with the babysitter. How does the nurse best explain this behavior?
a. Crying when left with the sitter may indicate difficulty with building trust.
b. Stranger anxiety should not occur until toddler-hood; this concern should be investigated.
c. Separation anxiety is normal at this age; the infant recognizes parents as separate beings.
d. Perhaps the sitter doesn’t meet the infant’s needs; choose a different sitter.
4. The nurse is providing anticipatory guidance to the mother of a 6-month-old infant. What is the best instruction by the nurse in relation to the infant’s oral health?
a. “Start brushing her teeth after all the baby teeth come in.”
b. “Use a washcloth with toothpaste to clean her mouth.”
c. “Clean your baby’s gums, then new teeth, with a washcloth.”
d. “Rinse your baby’s mouth with water after every feeding.”
5. A 9-month-old infant’s mother is questioning why cow’s milk is not recommended in the first year of life as it is much cheaper than formula. What rationale does the nurse include in her response?
a. It is permissible to substitute cow’s milk for formula at this age as he is so close to 1 year old.
b. Cow’s milk is iron poor and does not provide the proper balance of nutrients for the infant.
c. As long as the mother provides whole milk, rather than skim, she can start cow’s milk in infancy.
d. If the mother cannot afford the infant formula, she should dilute it to make it last longer.
CRITICAL THINKING EXERCISES
1. The mother of an 11-month-old boy who was born at 24 weeks’ gestation is concerned about his size and motor skills. What information should the nurse provide?
2. An infant’s mother thinks there may be something wrong with him because “he spits up so much.” What further information should the nurse obtain?
3. If you determine that the infant in the question above is experiencing normal spitting up associated with his developmental age, develop a brief teaching plan to review with the mother.
STUDY ACTIVITIES
1. A mother brings her 9-month-old boy to the clinic for a well-child check-up. She has questions about feeding, speech, and walking. Develop a teaching plan of anticipatory guidance for the 9-month-old infant.
2. Develop a safety plan for the 12-month-old infant.
3. In the clinical setting, observe two infants of the same age, one who is developing appropriately for his or her age and one who is delayed. Note the similarities and differences between the two infants.