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5Infant Development (Birth–12 months)

“Even miracles take a little time.” Cinderella’s Fairy Godmother

Learning Objectives

After studying this chapter you will be able to:

ሁ Name six infant reflexes. ሁ Explain the two typical motor development patterns seen in infants. ሁ Describe how an infant learns through the five senses. ሁ Explain the development of attachment in the first year of life. ሁ Describe the basic behaviors infants use in communication. ሁ Identify five red flags in infancy that require attention from a professional.

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Section 5.1 Areas of Development in Infancy

Chapter Outline Chapter Overview

5.1 Areas of Development in Infancy

5.2 Physical Growth and Brain Development in Infancy

5.3 Motor Development in Infancy

5.4 Cognitive Development in Infancy

5.5 Communication Development in Infancy

5.6 Social-Emotional Development in Infancy

5.7 Attending to the Infant’s Basic Needs

5.8 Developmental Red Flags and Where to Get Help

Summary and Resources

Chapter Overview At birth, human babies enter the world as entirely dependent and helpless organisms. How- ever, infancy, the period from birth until 12 months of age, is a period of rapid and amazing development. Infancy begins with a newborn who is completely reliant on others, and who is unguarded from all environmental influences. The nervous system and all components of the brain are developing and are vulnerable in this early stage of life, so much so that attention and memory may be affected far into the future by experiences that occur at this time. For infants, not only do their basic needs require careful attention, but also their sensory abili- ties, reflexes, self-regulation, and temperament need consideration, so that appropriate levels of stimulation can be offered and so that any serious atypical development can be identified early. This first year of life brings about major changes in communication; self-recognition; and the development of trust, autonomy, and emotional relationships with others.

As discussed in Chapter 4, the first 4 weeks of life are known as the neonatal period. During this period, an infant learns the early skills of survival and independence. This is where the discussion in this chapter begins. In addition to focusing on the infant’s rapid physical growth and continued neurological development, this chapter details the infant’s progress in each of the developmental domains, emphasizing reflexes, social-emotional competencies, com- munication, learning through the senses, and the infant’s basic needs of nurturance, feeding, diaper changing, rest, and appropriate levels of stimulation.

5.1 Areas of Development in Infancy As introduced in Chapter 1, child development is the dynamic process of acquiring increas- ingly more complex motor, cognition, communication, social-emotional, and self-help skills from the stage of conception through adolescence. Development includes milestones that follow a fairly predictable path but are influenced by genetics, experiences, and the environ- ment; as a result, development is very individualized.

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Section 5.2 Physical Growth and Brain Development in Infancy

It can be argued that infancy is one of the most fascinating of all of life’s developmental stages. A child’s innate abilities at this stage have been debated for years. Early beliefs held that the newborn comes into the world with little to contribute to the learning of skills and ideas, having to be taught everything from motor skills to self-help skills. Although current think- ing recognizes the newborn as completely dependent on others for survival, new knowledge has transformed beliefs about infants’ abilities. Through high-tech intrauterine observa- tions, neurological imaging, and other technological methods, information about life before birth and immediately after is growing tremendously. Learning is now known to begin in the womb, and most systems necessary for survival and intellectual advancement are ready at the time of birth.

The sections that follow provide detailed information regarding physical growth and brain development in infancy, as well as typical infant progress toward developmental milestones in the areas of motor, cognition, communication, and social-emotional skills. Several areas of caregiving related to an infant’s basic needs also are discussed, with caregiving behaviors set- ting the stage for the infant’s future development of self-help skills. These sections allow us to view the newborn within all areas of development, incrementally from birth until the child’s first birthday. This detailed view is necessary in order to best illustrate the capabilities the infant has at birth as well as the progress that is made over the first 12 months of life.

5.2 Physical Growth and Brain Development in Infancy An infant’s physical growth is quite impressive, and shows a wide range of what is considered “normal.” An infant’s physical growth is a composite of three measurements: weight, height (or length), and head circumference. Each of these measures is discussed in this section. In addition, because so much brain growth and development takes place during this period, that topic is addressed here as well.

Weight As noted in Chapter 4, the typical neonate weighs 7–7.5 pounds at birth. Most newborns lose weight in the first few days after birth. An average weight loss is about 5 percent of the infant’s birth weight. But after this loss, the typical infant gains about 5–7 ounces every week in the first month, doubles birth weight by 5 months, and typically triples birth weight by the first birthday (Hoecker, 2011). As pointed out in one of the early books on infant development, Infants, if this growth rate continued at the same rate as it does in the first 6 months, a 10 year old would be 100 feet tall and weigh about 240,000 tons (McCall, 1979). This certainly puts an infant’s early growth rate into perspective.

Infant weight gain is generally monitored regularly through well-child or pediatric visits. Clin- ical charts for infants are published in various forms. The U.S. Centers for Disease Control and Prevention (CDC) provides a commonly used set of 10 charts (5 for boys and 5 for girls), with the 5th, 10th, 25th, 50th, 75th, 90th, and 95th smoothed percentile lines shown on all charts, and the 85th percentile line shown for body-mass-index-for-age and weight-for-stature (see Figure 5.1). These charts are available in English, Spanish, and French and cover not only weight but also head circumference.

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lb kg

Age (months)

Weight-for-age percentiles: Girls, birth to 36 months

30 6 9 12 15 18 21 24 27 30 33 36

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Section 5.2 Physical Growth and Brain Development in Infancy

Failure to thrive refers to infants whose weight or rate of weight gain is significantly lower than that of other infants, at times presenting with diminished growth after typi- cal growth patterns had been observed previously (MedlinePlus, 2011). Failure to thrive can be due to a medical problem or the result of environmental issues such as abuse or neglect, poverty, poor eating habits, or parents’ lack of understanding about proper infant nutrition. Often, however, the cause of failure to thrive cannot be specifically identified. Children who are characterized by failure to thrive may show delays in their milestone skill development, and severe and prolonged failure to thrive may have long-term effects on a child’s developmental growth. However, if a cause can be determined and/or treat- ment can be provided quickly, a child’s developmental growth may not be severely affected (MedlinePlus, 2011).

Figure 5.1: Clinical charts, birth–36 months ሁ Clinical charts can be used to monitor infants’ weight gain. The U.S. Centers for Disease Control

and Prevention publishes a series of such charts. The child’s age and sex determine which version of the chart should be used.

Source: Adapted from Kuczmarski, R. J., Ogden, C. L., Guo, S. S., Grummer-Strawn, L. M., Flegal, K. M., Mei, Z., . . . , Johnson, C. L. (2002). 2000 CDC growth charts for

the United States: Methods and development. National Center for Health Statistics. Vital and Health Statistics 11(246).

lb kg

Age (months)

Weight-for-age percentiles: Girls, birth to 36 months

30 6 9 12 15 18 21 24 27 30 33 36

97th 95th

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30 6 9 12 15 18 21 24 27 30 33 36

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Weight-for-age percentiles: Boys, birth to 36 months

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Months

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Section 5.2 Physical Growth and Brain Development in Infancy

Length Along with weight, measurement of an infant’s length is needed to assess physical growth at this stage. Recumbent length is a measure of an infant’s physical growth (analogous to the height of older children and adults), and refers to the length of the infant while lying down. The CDC and the American Academy of Pediatrics recommend the use of the 2006 World Health Organization (WHO) international growth charts to monitor growth in children in the United States under age 24 months (WHO, n.d.). Growth curves are graphed by these growth charts from birth to age 2, by gender. (For one example of a growth chart, see Figure 5.2.)

There are general patterns that are considered typical for an infant’s growth. If an infant is determined to be far off the pattern for several routine pediatrician visits, a red flag should be raised to identify the cause and to decide whether an intervention is needed. For instance, extreme chronic malnutrition may produce stunted growth in children. The term stunted growth is generally used for children who fall below the 5th percentile of the reference popu- lation in height for age. This is where culture comes into play. The reference population for Asian children is different than that for children from the United States. Stunting is commonly found where poverty is extreme (including in the United States), with the conditions of pov- erty affecting how children are fed. Children below the poverty threshold experience stunt- ing at much higher rates (7–13 percent) than do those living above the poverty threshold (4–5 percent), as shown in Figure 5.3 (Lewit & Kerrebrock, 1997).

Figure 5.2: Length-for-age and height-for-age, for boys, birth–5 years ሁ This chart is a standard growth chart showing that the precise point where an infant lies on the

chart is not as important as the overall trend of growth.

Source: WHO Child Growth Standards (2014). Length/height-for-age: Birth to 5 years. Retrieved from http://www.who.int/childgrowth/standards/cht _lhfa_boys_p_0_5.pdf ?ua=1.

Months

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1 yearBirth 2 years 3 years 4 years 5 years

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2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10

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http://www.who.int/childgrowth/standards/cht_lhfa_boys_p_0_5.pdf?ua=1

0 2 to 5 years old 6 to 11 years old 12 to 17 years old

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Section 5.2 Physical Growth and Brain Development in Infancy

Important relationships have been identified between the number of years of malnutrition early in life and lower scores on tests of cognitive develop- ment (Korenman, Miller, & Sjaastad, 1995). However, research over the past three decades has shown that good nutrition after age 2 years can restore cognitive development (Brown & Pol- litt, 1996; Bryan, Osendarp, Hughes, Calvaresi, Baghurst, & van Klinken, 2004).

Head Circumference The third measurement of physical growth in infants is that of head cir- cumference. Head circumference is indicative of brain volume and is mea- sured by a tape around the forehead. An unusually shaped head is com- mon immediately after birth due to the birthing process through the birth

canal, but it lasts only hours or a few days. The infant head is large in proportion to the rest of the infant’s body, usually about one-fourth the size of the infant’s body length (Gairdner & Pearson, 1971). The skull also may appear large for the face and has parts that are soft because the bones have not fused yet. These soft spots are known as fontanels. The anterior fontanel can be found at the front top part of the head, a smaller one (the posterior fon- tanel) can be found at the back of the head, and smaller soft areas also may be found in other areas of the skull (Children’s Hospital of Wisconsin, 2013). The anterior fontanel is the one generally referred to when iden- tifying the soft spot. The posterior fontanel will close within the first few months, while the anterior fontanel will close at around 2 years (Children’s Hospital of Wisconsin, 2013). The American Academy of Pediat- rics (2013d) describes fontanels as being fairly durable but cautions against applying extreme pressure anywhere on a newborn, including the fontanels.

Brain Development The architecture of an infant’s brain is constructed from genetic information, with successive brain development shaped largely by experiences. During early gestation, brain cells called

▶ The Moro reflex can be a response to a loud noise or sudden loss of support. It includes rapid extension of arms followed by bringing them back to midline.

Figure 5.3: Stunting and the effects of poverty

ሁ Depending on age, children living below the official federal poverty threshold varied widely in the percentage falling in the range of stunting, whereas children in families over the poverty threshold have a much lower percentage of stunting.

Source: Lewit, E. M., & Kerrebrock, N. (1997). Population-based growth stunting. The Future of Children, 7(2), 149–156.

0 2 to 5 years old 6 to 11 years old 12 to 17 years old

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Amygdala (emotions)

HippocampusHippocampus (memory)

Prefrontal cortex

Amygdala (emotions) Hippocampus

(memory)

Section 5.2 Physical Growth and Brain Development in Infancy

neurons are developing by the millions. These neurons then travel to sites determined by genetics and form the layers of the brain. Neurons cluster together by the function they per- form. The clusters are connected to each other through a system of synapses, which are gaps between the clusters of neurons through which messages are sent.

All functioning, whether sensory or cognitive, is determined by this connecting of neurons. At the end of neurons are chemical messengers, such as adrenaline and serotonin, called neu- rotransmitters. Neurotransmitters activate areas of the brain at different times so that it can produce thoughts, emotions, and behaviors. The critical connections of groups of neurons are strengthened and become denser by being used, and are eliminated by not being used. The elimination of these unneeded connections or synapses is called pruning (Webb, Monk, & Nelson, 2001).

Before birth and into early infancy, the less complex parts of the brain are developed. These parts include the brain stem and the midbrain, which control bodily functions such as breath- ing, blood pressure, heart rate, and sleeping. Over the rest of the first year and through the next 2 years, the more complex parts of the brain in the limbic system are shaped and devel- oped (see Figure 5.4).

The limbic system is responsible for processing experiences and developing controls for emo- tions. Not until adolescence are the prefrontal cortex and the rest of the cortical areas that control abstract thinking and executive functioning (see Chapter 2) fully developed. There- fore, early experiences teach the brain how to react and also continue to influence develop- ment of the brain through adolescence. It is quite clear that early childhood caregivers have a huge influence in shaping the brain and, hence, the child’s future abilities and behaviors.

Although a critical amount of brain development occurs early and is influenced immensely by experiences, for young children who have difficult beginnings, researchers have identi- fied the brain’s ability to change, and its ability to change in a positive way. As described in

Figure 5.4: The limbic system ሁ This lateral view of an adult brain illustrates the prefrontal cortex, amygdala (emotions), and

hippocampus (memory).

Amygdala (emotions)

HippocampusHippocampus (memory)

Prefrontal cortex

Amygdala (emotions) Hippocampus

(memory)

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Section 5.3 Motor Development in Infancy

Chapter 1, the brain’s natural ability to change is called plasticity. Researchers have found that in the early stages of brain development there is a great deal of plasticity. Plasticity can com- pensate for areas in the brain that have been damaged or did not develop typically. Because of this plasticity, experiences in the early years have a substantial influence on the brain’s development and functioning. Although negative experiences can have a detrimental influ- ence on brain development in early childhood, later experiences also have a significant influ- ence because of plasticity, which means that care from responsive and nurturing caregivers can compensate for earlier problems.

A group of infants to consider when examining brain development are those born prema- turely. With every additional week of gestation, the fetus’s brain is more developed. Risks to fetuses born prematurely include future problems with language, learning, coordination, and behavior (e.g., attention-deficit/hyperactivity disorder); the more premature the birth, the greater the risks (Black et al., 2008). In addition, extremely premature infants may have brain hemorrhages, which can cause a variety of deficits in cognitive and motor functioning (Shonkoff & Phillips, 2000).

5.3 Motor Development in Infancy Infants are born with protective reflexes in the motor domain. Most reflexes disappear within the first year, but some play a protective function for survival and remain throughout life. Reflexes specific to the period of infancy are identified in Table 4.5 of Chapter 4. These reflexes will be observed following birth but fade over the first year of life. Reflexes that serve a pro- tective function during infancy and that remain throughout life include the gag reflex, which protects an infant from choking while sucking and drinking; the blink reflex, which protects the infant’s eyes from foreign particles; and the shiver reflex, which signals to caregivers that the infant is experiencing uncomfortable temperatures (Muller et al., 2013). Although suck- ing is considered a reflex at birth, it becomes voluntary at about 2 months and becomes per- manent. In coordination with the suck reflex, the swallowing reflex is established at birth. Voluntary swallowing develops sometime in the middle of the first year in time for solid foods to be introduced into the infant’s diet.

Other infant reflexes disappear within the first year as maturation of the central nervous system allows voluntary movements to take their place (Zafeiriou, 2004). The palmar grasp reflex is produced by putting pressure on an infant’s palm. The fingers will curl and grasp the pressure-producing object. This reflex weakens in the third month and disappears by the end of the first year. The stepping reflex is observed immediately after birth in full-term infants and disappears at around 2 months. It is elicited when the child is held upright with toes touching a surface and reciprocal “walking” movements of the legs are observed. This pattern of movement is a precursor to independent walking later in life (Bradley, 2003).

Even more reflexes disappear at around 4–5 months. One such reflex is the rooting reflex. This reflex occurs when an infant’s cheek is stroked lightly. The head turns in the direction of that cheek; the infant opens his or her mouth, and attempts to suck. The asymmetrical tonic neck reflex is sometimes referred to as the fencing position because the infant’s head turns to one side, while the arm and leg on that side extend and the limbs on the other side

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Section 5.3 Motor Development in Infancy

flex, making the infant look like a fencer (Clopton, 2000). The Moro reflex, also called the startle reflex, is a reaction to a startling stimulus such as a sudden loud noise. This stimulus causes the infant’s arms to extend and rapidly come back to midline while the fingers close and release in a grasping motion (Ronnqvist, 1995).

Newborns’ skills in the fine and gross motor domains are limited, as is seen in the uncoordi- nated movements of the legs and arms. However, their motor development follows two pat- terns that, once understood, make infant motor development seem very orderly and logical. These two patterns—cephalocaudal and proximodistal development—take motor develop- ment from the simple to the advanced.

Cephalocaudal development refers to how body growth and muscular control proceeds from top down or from the head to the legs. The infant smiles, gains head control, and is able to lift the upper trunk, in that order. This is followed by arm control, which comes before sit- ting up (which requires trunk or core control), followed by the gaining of strength and coor- dination in the legs.

Proximodistal development is motor development progressing from the center of the body to the extremities. The infant must first gain proximal stability in the musculature of the trunk before mastering more refined distal movements. An infant’s muscle strength fol- lows the same pattern. In the first month, an infant attains good muscle strength in the upper body. Control of the upper trunk and shoulders will be followed by reaching, which is then followed by grasping or object manipulation. This pattern is also observed in the motor sequence of crawling: As core control improves, the child will begin to rock on all fours until proximal extremity strength is achieved, allowing progression of strength development to the limbs. Based on this proximodistal motor development, it makes sense that, depending on the progressive development of strength and stability of musculature, the infant smiles at 2 months, then lifts the shoulders and chest at 3 months. At 3–5 months, the infant is able to hold the head steady and can roll over, bear weight on legs, reach out for toys, and play with hands and feet.

Finally, the infant is able to sit independently at about 5 months and can creep, crawl, and cruise along furniture by the second half of the first year. Walking is a milestone that parents often anticipate with special joy. As with other motor milestones, the ability to walk varies in its precise age of onset, but it typically appears at approximately 12 months.

These cephalocaudal and proximodistal growth patterns explain why fine motor skills develop after many of the gross motor skills are achieved. Different from the innate palmar grasp reflex discussed previously, infants develop the voluntary motor skill of grasping objects with the palm, called the palmar grasp. This palmar grasp typically develops before the more advanced pincer grasp, in which infants use the index finger and thumb to pick up objects. At about 3 months, infants typically can bring their hands toward midline. Midline refers to the center of the body if a line were to be drawn from head to toe with left and right sides of the body equivalent. At about 6–9 months, infants are able to use this skill to transfer toys from one hand to the other. From 9 to 12 months, infants develop the ability to isolate the index finger to point and to push buttons, and many motor skills combine to enable infants to feed themselves finger foods at this time.

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Section 5.4 Cognitive Development in Infancy

5.4 Cognitive Development in Infancy Cognitive development in newborns and infants is interrelated with each of the other devel- opmental domains. However, this cognitive development initially is based in the five senses of hearing, vision, touch, smell, and taste. Each of the senses is functional at birth and becomes refined in the first year (see Table 5.1).

The infant is born with selective but good hearing. Many studies have demonstrated infants’ ability to discriminate among voices, especially responding to female voices with preference for the mother’s voice (Fernald, 1985). Within a few months, the infant can coordinate the behaviors of listening and looking, and turning voluntarily toward sounds. Infants also seem to enjoy musical sounds at this time.

Visually, newborns attend more readily to moving objects than to static ones. They are able to follow moving objects if the objects are close enough to see. Infants cannot yet distinguish all colors, but they are able to see and focus on black-and-white patterns. Acuity, or visual clarity, is weak in early infancy, and two-dimensional visual skills likewise are poor. However, acuity, visual tracking of a moving object in all directions, and depth perception improve in the first 6–8 months so that by the second half of the year vision is comparable to that of an adult. This means that infants recognize color and shapes and see at a distance.

Jean Piaget’s theory of cognitive development (see Chapter 3) identifies four main stages. In the first year of life, children are within what Piaget referred to as the sensorimotor stage. Object permanence is an important part of Piaget’s sensorimotor stage. Object permanence is the ability to know that objects exist even when they cannot be seen, heard, or touched. It is thought to be an important cognitive milestone that usually occurs after the age of 4 months. Object permanence is connected to the senses since the object first must be recog- nized through the senses, usually by vision. It is a significant milestone because it also signals that the infant is developing memory and some abstract thinking.

The sense of touch is also not very sophisticated at birth, but it is present. Newborns’ responses to touch often are by reflexes, but gradually they begin to discriminate between

TIPS ON PROMOTING MOTOR DEVELOPMENT IN INFANCY • Engage an infant in play. • Present toys that stimulate the infant’s senses to encourage the infant to move

eyes, head, and neck to see what you have. This can also encourage older infants to reach and grab for toys, promoting fine motor skills.

• Without causing frustration, place a toy just out of the infant’s reach to encourage the development of skills used to move toward and grasp objects.

• Use tummy time (occasionally placing a supervised infant on his or her stomach during awake time) to help strengthen muscles and improve motor skills. Provide interesting toys and interact with the infant during this activity.

• Before an infant begins to stand and cruise, make sure furniture and items low to the floor are safe and stable for the infant to hold onto and walk around.

• Allow an infant to self-feed (when ready) with finger foods. This helps the child to develop fine motor skills.

Source: Harding, S. (2013). Activities to encourage the motor development of a baby. Retrieved from http://www.livestrong .com/article/82666-activities-encourage-motor-development-baby/.

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http://www.livestrong.com/article/82666-activities-encourage-motor-development-baby/

Section 5.4 Cognitive Development in Infancy

touch that is preferred and touch that is not. For instance, infants may like being patted on the back to fall asleep and may enjoy skin-to-skin cuddling. Mouthing is another way infants experience touch and exploration. This behavior begins in the first half of the year, but an infant needs more developed motor skills in order to bring an object, whether a toy or body part, to the mouth.

Researchers have found that neonates are able to discriminate between odors by looking in the direction of the more pleasant ones, with their favorite being their mothers’ (Cernoch & Porter, 1985). Taste is also somewhat selective. Most infants prefer sweet tastes to salty or tasteless ones.

Table 5.1: Senses in infancy

Sense Characteristics

Hearing Infants are born with selective but good hearing, as they have been shown to discriminate among voices.

Within a few months, infants can coordinate the behaviors of listening and looking, turning voluntarily toward sounds.

Vision Newborns attend more readily to moving objects than to static ones.

Newborns can follow moving objects if the objects are close enough to see.

Infants cannot yet distinguish all colors, but they are able to see and focus on black-and- white patterns.

Acuity (visual clarity) is weak in early infancy.

Two-dimensional visual skills are poor in early infancy.

Acuity, visual tracking of a moving object in all directions, and depth perception improve in the first 6–8 months; by the second half of the year vision is comparable to that of adults.

Touch The sense of touch is also not very sophisticated at birth, but it is present.

Often the newborn’s responses to touch are by reflexes, but gradually they begin to discrimi- nate between touch that is preferred and touch that is not.

Smell Neonates are able to discriminate between odors by looking in the direction of the more pleasant ones, with their favorite being their mothers’.

Taste Most infants prefer sweet tastes to salty or tasteless ones.

TIPS ON PROMOTING COGNITIVE DEVELOPMENT IN INFANCY • Provide infants with interesting toys and experiences. • Talk to infants. Respond to infants’ smiles and vocalizations. • Read and sing to infants. • Provide infants with adequate nutrition.

• Provide infants with sensitive and responsive care. • PLAY! • Allow infants to touch and mouth objects that are safe. Infants learn through all of

their senses. • Provide toys that stimulate all of an infant’s senses. • Follow an infant’s cues for the need for more or less stimulation.

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Section 5.5 Communication Development in Infancy

A relatively recent debate among caregivers is the use of technology and media with infants. The American Academy of Pediatrics (2011a, 2011b), the National Association for the Educa- tion of the Young Child and the Fred Rogers Center for Early Learning and Children’s Media (2012), and the White House Task Force on Childhood Obesity (2010) discourage the use of screen media for children under 2 years of age in early childhood programs. However, there is agreement that some technology such as music and audio recordings, if used intentionally and in an age-appropriate manner, can enhance the quality of programs. Mixed messages about the use of technology for infants has much to do with the use of passive technology like television versus the use of interactive technology that, when combined with adult involve- ment such as modeling its use and partnering in play, can help build relationships, feed curi- osity, and improve communication and social skills (Plowman & Stephen, 2005).

5.5 Communication Development in Infancy Communication and language are key to social interactions, building relationships, and other critical skills later in life. In addition to being directly related to the social-emotional domain, it is difficult to separate communication skills from the cognitive domain since an infant’s communication is often seen as the vehicle by which cognition and intelligence are assessed. For example, if a baby cannot communicate with caregivers, the caregiver could not know what the baby understands, or develop a reciprocal relationship.

Communication is typically separated into two categories: receptive and expressive. Receptive communication skills are generally apparent sooner than are expressive skills. Receptive communication includes symbols like words, sounds, and gestures that an infant under- stands. Receptive communication skills are important for current and future learning; however, it is sometimes difficult to recognize if the infant is having challenges with these

MEDIA, TECHNOLOGY, AND EARLY CHILDHOOD: INFANTS AND TECHNOLOGY: A LOST OPPORTUNITY

Nancy cares for two infants, Louise and Carol (9 and 11 months old, respectively), in her home child care. Several times a day, she needs to prepare food, change bedding, and complete other chores related to their care. Nancy finds that leaving the infants

in safe seats to watch television during these times keeps them quiet. In addition, when she returns to the room they are in, the quiet suggests to her that she can leave them in front of the television longer so that she can have some quiet reading time for herself.

Screen time for children under 2 years old is discouraged by experts in child development (National Association for the Education of the Young Child and the Fred Rogers Center for Early Learning and Children’s Media, 2012) for many reasons but especially because children under age 2 need direct adult interaction and relationship-building activities. Therefore, if Nancy changes her use of technology for the infants in her care from passive watching of television to interactive activities led by her, she can supplement Louise’s and Carol’s oppor- tunities for improved development. For instance, Susie, another home child caregiver, folds her children’s laundry in the same room in which the children in her care are listening to soft music. She talks with the infants about what she is doing and sings with the music.

▶ Intentional communication occurs when infants use actions (like pointing) or vocalizations to influence a caregiver.

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Section 5.5 Communication Development in Infancy

receptive skills. Expressive communication includes how infants express themselves and communicate to others. Expressive communication is an equally impor- tant component of communication, and it signals to caregivers that receptive skills are being used.

Infancy is a time when many communication skills are gained, but researchers also recognize that infants are born with many capabilities to communicate. For instance, infants communicate specific needs early (Owens, 2001). The earliest forms of infant communi- cation are nonverbal or preverbal communication. The typical infant often begins communication with crying. The infant cries to signal the need for food, nurturance, and comfort, including the need for a diaper change. Gen- erally in the first 3 months, infants also coo and use other similar sounds of pleasure as well as smiling to commu- nicate contentment.

Infants also use early nonvocal communication through facial expressions, head turning, and reaching. They react to loud sounds, recognize familiar voices, and calm down to those voices if they are upset. In the next 3 months, infants pay attention to changes in voice

tones and to music. They can follow sounds with their eyes and are aware of toys that make sounds. They express themselves with even more sounds than in the first 3 months by adding babbling and gurgling sounds. They begin to laugh out loud and babble in response to emotions like being excited (American Speech-Language-Hearing Association, 2013; National Institute on Deafness and Other Communication Disorders [NIDCD], 2010).

During the second half of the first year, infants imitate speech sounds and may say one or two simple words like “dada,” “up,” and “mama.” This stage in communication development is called the sound imitation period. One form of sound imitation is echolalia. Echolalia is when infants imitate sounds, not real words, they hear in their environments, including sounds from people. It occurs at around 9 months.

At about this same time, infants begin to attend more carefully when caregivers talk to them. Thus it becomes apparent through the infant’s communication skills that infants under- stand some words for common items like “milk” and “dog” and react to simple phrases like “come here.” The use of gestures to communicate desires, such as wanting to eat or wanting to be picked up, begin at 7–12 months of age (NIDCD, 2010). This is the beginning of intentional communication. Intentional communication is demonstrated when infants deliberately communicate by using either actions or vocalization to get something (Owens, 2001). The difference in this type of communication, as compared with other types, is in its use as the means to get a response from another. See Table 5.2 for distinctions among types of infant communication.

MEDIA, TECHNOLOGY, AND EARLY CHILDHOOD: INFANTS AND TECHNOLOGY: A LOST OPPORTUNITY

▶ Intentional communication occurs when infants use actions (like pointing) or vocalizations to influence a caregiver.

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Section 5.5 Communication Development in Infancy

Table 5.2: Types of infant communication

Type of Communication Description Approximate Age

Nonverbal/ preverbal

Cries to signal needs, including the need for food, nurturance, and comfort.

Coos and uses other similar sounds of pleasure

Smiles to communicate contentment

Pays attention to music

Laughs

Understands basic sounds of native language

Obviously listens to words by turning and physically reacting

Birth–9 months

Simple words/ intentional gestures

Waves, holds up arms to be picked up

Understands common words

Responds to simple requests

Imitates speech sounds

Has one or two words

9–12 months

Some language specialists believe that before infants can move on to using words and sen- tences, they must have a conceptual framework of their environment and intentional com- munication is the last step in this framework. This framework is made up of three sequential

TIPS ON PROMOTING COMMUNICATION DEVELOPMENT IN INFANCY • Be engaging when talking to infants; respond to their vocalizations. • Engage in joint attention. Point to objects and talk about what you and the

infant see. • Describe to infants the objects they see, the activities in which they take part, and

events that occur. • Use a variety of words and grammar. • Label objects and actions. • Let infants take part in interesting activities. • Read books (and read them over and over!). • Introduce and talk about new and interesting objects. • Involve infants in musical activities; sing nursery rhymes and children’s songs. • Use gestures or simple signs when talking.

Source: Gardner-Neblett, N., & Gallagher, K. C. (2013). More than baby talk: 10 ways to promote the language and com- munication skills of infants and toddlers. Chapel Hill: University of North Carolina, FPG Child Development Institute.

Figure 5.5: Three components necessary for first words and sentences

ሁ For infants to begin to use words and sentences, some language specialists believe that they must have a conceptual framework of their environment, which is made up of conceptual development, speech/signal decoding, and intentionality.

Source: From De Villiers, J. G., & De Villiers, P. A. (1999). Language development. In Develop- mental psychology: An advanced textbook (4th ed.). Copyright © 1999 Lawrence Erlbaum Associates, Inc. Reprinted by permission.

Conceptual Development

Speech/Signal Decoding

First Words and Sentences

Intentionality

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Conceptual Development

Speech/Signal Decoding

First Words and Sentences

Intentionality

Section 5.6 Social-Emotional Development in Infancy

components. First, infants must have the cognitive development skills to know that objects and people are stable and that there are categories of objects. Second, they must sepa- rate speech into words and phrases by decoding speech or other symbols. This decoding helps the infant to rec- ognize the same word or symbol when used at different times and when used by different people. Third, they must learn how to be intentional when they want something, meaning that they are communicating for a particular purpose. Only after all three steps are achieved can the infant begin to use words and sentences (see Figure 5.5) (de Villiers & de Villiers, 1999).

5.6 Social-Emotional Development in Infancy Infant social-emotional development begins with the neonate’s bonding experience described in Chapter 4, as well as all social interactions and early relationships. Early behaviors that demonstrate that infants have emotions include laughing and smiling, showing anticipation and excitement (possibly through arms and legs flailing), and switching from quiet to alert states when paying attention to the environment.

The intense closeness an infant feels to the attachment figure is part of social-emotional development. The infant sends out signals that encourage relationships by mutual gazing, cooing, cuddling when held, and smiling. Some researchers say the grasp reflex is demonstra- tive of this innate desire, based on the infant’s strong grasp of a parent’s fingers, but there is no evidence for this interpretation.

According to attachment theory (see Chapter 3), attachment is the basis for social- emotional well-being, which is the basis for good future mental health. Attachment behaviors are observed in all healthy infants. These behaviors include clinging to a caregiver, crying when the attachment figure leaves the infant, and in later infancy, clinging and crying when a stranger approaches. In addition, infants use different strategies to seek out a familiar per- son or object, at first visually and later with locomotion, given that making eye contact and physical touching are also behaviors that promote relationships. Those individuals who most often become attachment figures are caregivers who are responsive to the infant’s cues and signals, are typically sensitive in their style of caregiving, and who are stable in the infant’s life (Ainsworth, 1979).

Table 5.2: Types of infant communication

Type of Communication Description Approximate Age

Nonverbal/ preverbal

Cries to signal needs, including the need for food, nurturance, and comfort.

Coos and uses other similar sounds of pleasure

Smiles to communicate contentment

Pays attention to music

Laughs

Understands basic sounds of native language

Obviously listens to words by turning and physically reacting

Birth–9 months

Simple words/ intentional gestures

Waves, holds up arms to be picked up

Understands common words

Responds to simple requests

Imitates speech sounds

Has one or two words

9–12 months

infant see. • Describe to infants the objects they see, the activities in which they take part, and

Figure 5.5: Three components necessary for first words and sentences

Conceptual Development

Speech/Signal Decoding

First Words and Sentences

Intentionality

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Section 5.6 Social-Emotional Development in Infancy

Attachment and relationship building have been described as having phases within the infancy stage (Ainsworth, 1982; Ainsworth, Blehar, Waters, & Wall, 1978). In phase 1, which is approximately the first 2 months of infancy, there is little discrimination among caregivers or objects. However, infant behaviors of crying, cuddling, and smiling promote caregivers’ interactions. In phase 2, during the next 4 months and sometimes much later, differentiation among caregivers becomes the typical behavior, with obvious preferences for familiar indi- viduals. Beginning at about 6 or 7 months but by 2 years, the toddler is clearly attached to one or more figures (Lamb, Thompson, Gardner, & Charnov, 1985). See Table 5.3 for a more detailed look at the phases of attachment according to John Bowlby (1969). This forming of attachments early in life is believed to be important throughout life.

Table 5.3: Phases of attachment according to Bowlby (1969)

Phase Approximate Age Characteristics

Phase 1: Orientation and signals with limited discrimination of figure

Birth to 2 months (but may last up to 3 months or later)

Little discrimination among caregivers or objects.

Infant behavior of crying, cuddling, grasping, reach- ing, and smiling promotes caregivers’ interactions and proximity.

Phase 2: Orientation and signals directed toward one (or more) discriminated figure(s)

Following phase 1 until about 6 months of age or later

Differentiation among caregivers with obvious preferences for familiar individuals.

Continued friendly behavior toward others, but more distinctly toward the primary attachment figure than toward others.

TIPS ON FOSTERING THE ATTACHMENT RELATIONSHIP • Be sensitive and responsive to children’s needs; be warm and affectionate. • Read and respond to the cues that children show. • Engage children by taking turns during interactions and when communicating. • Be physically and emotionally available when children explore the environment.

• Provide comfort when children are distressed. • Enthusiastically follow a child’s lead during play, and provide help to support a child’s

problem-solving skills. • Keep in mind that relationships can be built and strengthened at any time during the day. • Communicate to children that you will keep them safe. • Provide consistency in the care that children receive (including primary caregivers and

child-care providers). • Maintain consistent caregiving, especially when a child’s environment changes (e.g.,

moving to a new home, transitioning to a new child-care classroom). • As a caregiver, locate any needed mental health support or other needed resources so

that you can maintain warm and responsive interactions with the children in your care. Source: Modified from Wittmer, D. (2011). Attachment: What works? Retrieved from http://csefel.vanderbilt.edu/briefs /wwb_24.pdf.

(continued)

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Section 5.6 Social-Emotional Development in Infancy

Phase Approximate Age Characteristics

Phase 3: Maintenance of proximity to a discriminated figure by means of locomotion as well as signals

Begins at 6–7 months and continues into the third year

Increasing discrimination in the way caregivers are treated.

Follows a preferred caregiver when she leaves; greets a preferred caregiver when she returns.

Uses preferred caregiver as a safe base in order to explore.

Other caregivers can be identified as secondary attachment figures.

Strangers are treated with increasing caution and become cause for alarm.

Some behavior becomes organized and goal- directed toward the primary attachment figure.

Proximity to attachment figure is beginning to be maintained.

Phase 4: Formation of a goal-directed partnership

Begins about the middle of the third year

The child gains insight into the primary attachment figure’s “feelings and motives” (p. 219).

A more complex relationship develops, which Bowlby refers to as a partnership.

Source: Bowlby, J. (1969). Attachment and loss. Vol. 1: Attachment. New York: Basic Books.

Social-emotional characteristics that infants are considered to be born with include tempera- ment and personality traits. Evidence indicates that temperament and personality traits are stable over time, but how a child expresses them later depends on early relationships, culture, and other environmental factors (Lamb, 1988; Shonkoff & Phillips, 2000). Emotions and their expressions are other characteristics in an infant’s early social-emotional development. These expressions of emotion are often related to the infant’s response to stress and are identified in the infant’s ability to self-control or regulate stress. Behaviors include crying, tantrums, rocking, and turning away. Controlling nega- tive emotions early is viewed as the healthy interaction between reflex responses and cognitive abilities (Kopp, 1989).

Some child psychologists believe that the emotion of empathy, or the concern for oth- ers in distress, is vital in life. In the past, this experience was believed to develop some- time after the child’s second birthday, as developmentalists reasoned that younger children could not yet see themselves as separate from others, and thus could not feel empathy or concern for another individ- ual (Hoffman, 2000). Infants were thought to experience emotional distress but not to

▶ Empathetic concern is demonstrated by infants’ attention to a crying peer.

Table 5.3: Phases of attachment according to Bowlby (1969) (continued)

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Section 5.7 Attending to the Infant’s Basic Needs

have the ability to distinguish whether this distress was their own or another’s. This would cause infants to soothe themselves. Recent research finds this not to be the case. Empathic concern is shown to exist during the first year of life and is evident through infants’ social nature (Davidov, Zahn-Waxler, Roth-Hanania, & Knafo, 2013) and their behaviors of focusing attention on crying peers through gesturing or touching.

5.7 Attending to the Infant’s Basic Needs The infancy period cannot be discussed without addressing the infant’s basic needs. This period of life is dominated by changes, questions, and concerns about how best to care for an infant. Close attention to an infant’s needs may offer many clues to the health and early devel- opment of that infant. Infants are born with many skills that their caregivers underestimate. However, infants need caregivers to meet their needs through attentive and responsive care during the first year of life. Infants change a great deal in these first 12 months, with appropri- ate care allowing for an infant’s developmental gains and the early stages of important skills in the self-help domain. The self-help domain becomes a prime focus during toddlerhood (see Chapter 6). For the first year, however, the focus is placed instead on the caregiver’s identify- ing how to best meet the infant’s needs.

For instance, after the neonatal period, an infant’s sleeping patterns make many parents think they will live the rest of their lives sleep deprived. Then a few months later the infant is sleeping peacefully for long stretches of time. Elimination initially is a constant clean-up task and every aspect of it is examined by the new parents, who see it as a window to inter- nal health. Then patterns develop and consistency and frequency are possible to determine.

Next, feeding a newborn seems like a continuous activity because soon after one feeding it is time for the next. This leaves parents wondering if the infant ate enough, is eating enough, or will eat enough during the next feeding. Bathing and dressing are not as routine as sleeping, eliminating, and feeding because it seems that all newborns do is sleep, eliminate, and eat, so they are changed often with no bathing schedule. Infants sometimes get rashes or peel- ing skin even if hygiene is conducted with care and deliberation. In reality, each infant has unique patterns in these areas, but all have the same basic caregiving needs. The following subsections provide a glimpse into what can be expected or not expected in meeting infants’ basic needs.

Sleeping Newborns and infants need a lot of sleep. As described in Chapter 4, neonates can sleep as much as 18 hours a day. This diminishes by about 4–6 months, when infants may sleep approximately 9–12 hours a night (waking several times for feeding) with several naps dur- ing the day lasting 30 minutes to 2 hours. They do not have regular sleep cycles until about 6 months. Helpful to sleeping through the night is “growing out” of nighttime feedings. Impor- tant for getting infants to sleep on their own is to develop consistent bedtime routines and to put them to bed when they are drowsy but not asleep (National Sleep Foundation, 2013).

Infants go through six states of consciousness through most days of their first month. Two are sleep states (see Table 5.4) and four are states of relative alertness. State 1 is deep sleep. The infant does not move while in this state. During more active, lighter sleep, considered to be state two, noise may awaken the infant. During state 2, rapid movements of the eyes while

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Section 5.7 Attending to the Infant’s Basic Needs

closed can be seen. Infants typically alternate between these two states. State 3 is when the infant starts to fall asleep. In state 4, the infant may be awake but generally will be quiet and inactive. State 5 is an alert and active state. State 6 is when the infant cries and seems upset (American Academy of Pediatrics, 2013c).

Table 5.4: Infant sleep states

Sleep State Description

Non-REM sleep Non-REM sleep is actually made up of 4 sleep stages. They are separate from one another because of the distinct brain wave patterns produced in each stage, and the infant may cycle through all of the stages many times while sleeping:

• Stage 1: The infant is “dozing off.” This stage marks the beginning of the sleep cycle; it is the transition between wakefulness and sleep, when the infant’s eyes become droopy and start to close.

• Stage 2: The infant is lightly sleeping and may still startle at noises. • Stages 3 and 4: The infant is falling into a deeper sleep and does not move or

make sounds. After Stage 4 of non-REM sleep, the infant will transition back down to Stage 3, then to 2, and will then enter REM sleep. The infant may wake up and have trouble falling back to sleep while making these transitions.

Rapid eye movement (REM) sleep

During REM sleep, the brain is active and the eyes move back and forth rapidly, hence the name. REM is when dreaming occurs, and for infants this type of sleep comprises about 50% of their total sleep. Newborns and infants typically need about 16 hours of sleep per day, but as children age and grow into adult- hood, they require less REM sleep and fewer hours of sleep in general.

Source: Adapted from Stanfordchildrens.org. (n.d.). Newborn-sleep patterns. Retrieved from http://www.stanfordchildrens .org/en/topic/default?id=newborn-sleep-patterns-90-P02632, and Nueroscience for kids—Sleep. (n.d.). Retrieved from https://faculty.washington.edu/chudler/sleep.html.

By the end of the first year, infants should have nights and days figured out so that longer sleep periods occur during the night. Sleep problems such as insufficient sleep and poor-quality sleep have been associated with impaired cognitive functioning and have been shown to be related to problems in attention, learning, memory, and later academic achievement (Hill, Hogan, & Karmil- off-Smith, 2007; Stores, 2007). Sleep problems are more common in toddlers and preschoolers than in newborns and infants.

During infancy there is the fear of sudden infant death syndrome, known as SIDS. SIDS is the sudden death, during sleep, of an infant who appeared to be healthy. A definitive explanation for an infant’s death cannot be identified in cases of SIDS. Typically the infant dies after having been put to bed. SIDS is the most common cause of death in the United States for infants ages 1–6 months (Nagler, 2002). SIDS prevention strategies include put- ting infants to sleep on their backs, using a firm mattress, having infants sleep in their own beds, and keeping loose bedding and toys out of the bed. A “back to sleep” cam- paign in the United States emphasizes the need to leave

Purestock/Thinkstock

▶ Recommendations to reduce the risk of sudden infant death syndrome include putting infants to sleep on their backs and using a firm mattress without loose bedding.

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https://faculty.washington.edu/chudler/sleep.html

Section 5.7 Attending to the Infant’s Basic Needs

the infant lying face up when being put to bed. One of the possible explanations for SIDS is that these infants have problems with the part of the brain that controls breathing, and arousal from sleep does not occur (Mayo Clinic Staff, 2011a).

Sheila wanted nothing more than for her family to get a restful night. She sensed the family’s exhaustion since Maggie had been born and now Maggie’s waking to feed frequently was stirring the entire family of five throughout the night. When Maggie woke at midnight for the first of her feedings, Sheila decided it would be easiest if she let Maggie return to sleep next to her so that she could respond quickly to her next request to feed. As Sheila next woke to the sun shining through the curtains, she knew immediately that something was wrong. Sheila could not wake Maggie. The doctors could give Sheila and her family no specific medical explanation for Maggie’s death. Sheila and her family were devastated by their loss. Sheila often went over and over in her head what could have hap- pened. Before Maggie’s death, Sheila had read about the “back to sleep” cam- paign, but she had not heard that many infant deaths are now thought to be the result of accidental suffocation. She often thinks, “If only I had put Maggie back in her crib, would that have saved her?” Now that she knows more, she has taken on the task of informing others about what happened so that other families can reduce the risk of this heartbreaking loss. As Sheila talks about the night she lost Maggie, she urges parents to give their babies a clear and safe space to sleep.

Feeding and Eating Infants need a lot of milk in the first few months. In the first two months, feedings may occur as often as every 2–4 hours for breast-fed babies and about every 3–4 hours for bottle-fed babies. Breast milk has several advantages over formula. The most important advantage is its immunity benefits. Breast milk has been shown to protect against illnesses common in child- hood, as well as to protect against infections and allergies (Kidshealth.org, 2013; National Institute of Child Health and Human Development, 2012). Also, nutritional advantages have been identified for breast milk, and breast-feeding has been shown to lead to a decrease in the likelihood of type 1 diabetes and obesity later in life (National Institute of Child Health and Human Development, 2012). Not only does breast-feeding show advantages for an infant’s physical health, but it also provides for an infant’s emotional health, based on the mother- child interactions during breast-feeding and the skin contact that occurs (National Institute of Child Health and Human Development, 2012). Nevertheless, based on a mother’s comfort level, the timing of feedings, a mother’s diet, restrictions due to a mother’s medical condi- tions or medications, and the convenience and flexibility factor, bottle-feeding has its own advantages (Kidshealth.org, 2013). Every mother must make the decision to breast-feed or not depending on many personal circumstances, and it is important to support the mother in whatever decision she makes regarding the feeding method selected.

If bottle-feeding is chosen for the baby, commonly used infant formulas generally fall into three main categories: (a) cow’s milk based, (b) soy based, and (c) elemental. Elemental for- mulas are used for infants who cannot tolerate cow’s milk or soy and are made from amino acids, the components that combine to form protein. Formulas are offered in powder, concen- trate, and ready-to-feed preparations. Caregivers should be aware of the importance of using iron-fortified infant formulas and should be cautioned against the use of microwave ovens to warm formula because it causes uneven heating and may burn the infant’s mouth or tongue. Also, bottles should never be propped or left with the infant without supervision. Propping may cause choking and aspiration (Kan & Sullivan, 2008).

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Section 5.7 Attending to the Infant’s Basic Needs

Infants have small stomachs and need to be feed often. Breast milk is digested easily and quickly. Formula takes longer to digest. In either case, on-demand feeding should be consid- ered. On-demand feeding is the feeding of babies when they cry or in some way give signals that they are hungry, like sucking their hands (Pryor & Pryor, n.d.). Decades ago, on-demand feeding was thought to lead to a spoiled child. However, Ainsworth and Bell (1969) found that infants fed on a schedule were less secure than infants fed on demand. At 4 months, the infant should show signs of anticipating feeding when the bottle or breast is in view. Monitoring of weight gain is a good indicator of whether or not the infant is eating enough.

As the infant gains weight, solid foods may be introduced as supplements to milk. This gener- ally happens at about 4–6 months. Tongue coordination is necessary for solid foods, so this motor development may be a factor in timing the introduction of solid foods. These foods must be moved from the front of the mouth to the back to be swallowed. If the infant cannot do this yet, it may be too early for such foods. If the infant is ready, solid food feeding often begins with baby cereal that is mostly liquid and then gradually made thicker. Pureed foods can be added if the cereal feeding is successful. Later, generally in the second half of the year, self-feeding of finger foods comes when fine motor grasping skills begin to develop.

Erin had read many books and magazines about what to expect during the first year of life. Formed in her head was this “life itinerary” that laid out nicely the expectations and milestones for her daughter, Lucy. Erin was amazed initially at how the various stages that had been described seemed to fit with Lucy’s devel- opment. Erin joked that child development writers were almost clairvoyant as they could predict within a narrow window of time the next emergent activ- ity or trait that Lucy would display. As time pressed on, Erin became no less amazed by how the predictions of these milestones continued, but she began to feel something was missing; namely, sleep. As outlined, Lucy’s feeding, sleeping, and diaper change patterns did become more predictable, but the endless cycle of attending to these needs meant months of little rest for Erin. While a book or magazine could sum up the process, Erin learned that it did not necessarily prepare her for the state of exhaustion she felt constantly or the roller coaster of emotions she felt: joy, anger, guilt, and insecurity. Years later and following the arrival of a second child, Erin now sees the first year differently. While it is a magical year in the tremendous development that occurs, Erin appreciates the bigger picture and understands that the impact on the entire family will ebb and flow. She knows that although this early period can be exhausting and demand- ing, it gets easier.

Elimination Elimination patterns vary considerably from infant to infant. Most pediatricians will say that after about a week newborns should have between four and six wet diapers a day, but this is not a definite number. A newborn’s urine may be pinkish or red especially right after birth, but if this continues beyond a few days a pediatrician should be contacted.

Infants who are breast-fed have loose and frequent stools, often after every feeding. The stools of a breast-fed baby may be green, yellow, or black and a variety of consistencies depending on the mother’s diet. The stools of a formula-fed infant are generally pasty and firm, yellow to brown or green in color. Some infants may not have a bowel movement for several days, but if they go too long, about a week, or if there is a sudden change in the consistency of an infant’s stool it would be advisable to call the pediatrician. When infants eliminate stools, they

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Section 5.7 Attending to the Infant’s Basic Needs

may exhibit straining behaviors that resemble a child who is constipated. Infants may grunt, grimace, and turn red while pulling up their legs because of the effort to eliminate while lying down (Kan & Sullivan, 2008). This behavior is typical, and only unusual consistency of the stool should be cause for intervention. The frequency of elimination should decrease after about 6 weeks, and the variety and patterns of elimination should become more predictable.

Hygiene Good hygiene practices carried out by caregivers during the first year of life help to keep an infant healthy and comfortable. It is important for caregivers to provide appropriate care and cleaning, based on an infant’s unique needs. If questions or concerns about this matter should arise, an infant’s pediatrician can be a trusted source of information for caregivers.

Infant Bathing

Newborns do not need daily bathing, and soap is not recommended when they do receive a bath. The use of soap may dry an infant’s skin and cause flaking. Plain water is recommended, but a mild cleanser with a neutral pH can be used (Kan & Sullivan, 2008). Hair can be washed with a mild shampoo or plain water also.

Even if all of the recommendations in infant bathing are followed, infants may develop scale- like rashes on their scalps and around the nose, behind the ears, and in the creases on the neck and armpits. The rash may appear yellow and crusty and is believed to be the normal buildup of skin oils (Canadian Paediatric Society, 2007). When this scale-like rash occurs only on the scalp, it is called cradle cap. It is considered to be a noninfectious dermatitis and is quite common in newborns. It is not thought to be uncomfortable for the infant and goes away gradually, disappearing slowly over a period of weeks or months. Unlike eczema or contact dermatitis, it is rarely uncomfortable or itchy and may not need special care.

The umbilical cord, however, does need special care in the postnatal period. Before birth the umbilical cord functions as the tubing that removes wastes and brings nourishment to the fetus from the placenta. The newborn’s connection to the placenta is separated at birth and a stump remains on the newborn’s stomach. The umbilical cord stump must be kept dry and clean, and whenever cleaning the area of the stump, hands must be clean, especially if diapers were handled. If the stump comes into contact with stool or urine, it should be cleaned with plain water and left exposed to air to dry or covered very loosely. The diaper should always be folded away from the area until the stump falls off and the site is healed. The umbilical cord stump usually falls off anywhere from 1 to 3 weeks after birth (Kan & Sullivan, 2008) and then the “belly button” is visible. Until then only sponge baths are recommended so that it is easier to keep the area dry for healing.

Infant Skin Care

Once again, plain water is best for washing an infant’s skin. Lotions and other lubricants are not necessary. Talcum powder of any sort should never be used because it can cause aspira- tion. The use of commercial wipes can be convenient and is fine if they are free of chemicals, alcohol, and fragrances. Diaper rashes may appear in spite of extreme care in cleansing. These rashes heal with simple zinc oxide. More difficult or resistant diaper rashes may need the attention of a health care professional (Kan & Sullivan, 2008).

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Section 5.8 Developmental Red Flags and Where to Get Help

Genitalia Care for Boys and Girls

Circumcision is the surgical removal of the skin covering the tip of the penis (Mayo Clinic Staff, 2012a). It is commonly done for newborn boys for religious reasons or family tradition, while some parents opt for the procedure for hygiene and health care reasons. For the male infant with an uncircumcised penis, pulling back of the foreskin is not necessary when bath- ing and plain water is once again recommended. If the penis was circumcised, it should be washed with warm water and gentle soap at every diaper change and lubricated with simple vitamin A & D ointments to prevent the skin from sticking to the diaper while it heals over a period of 1–2 weeks (Kan & Sullivan, 2008).

For female infants, the vaginal area should be washed gently with warm water by wiping from the front to the back. A white or bloody discharge is common in the early neonatal period as a result of the fetus’s absorption of maternal hormones.

Dressing The question of how infants should be dressed is based not on style but rather on safety and health. Strings and loose decorative items on clothing are not appropriate for infants. Common sense should drive caregivers’ decisions regarding infant clothes. For instance, the temperature of the infant’s environment should be a major factor in deciding how much an infant should wear. Protection from sun in the summer and from cold in the winter is a key determinant of an infant’s clothing. Infants have delicate skin and should be shaded from direct sunlight. Babies should be monitored frequently for overheating. However, if the infant is in an air-conditioned environment, warmer clothes are necessary.

Healthy infants do not need to be dressed more warmly in the winter than the adults they are with. This rule is a handy guide in most cases unless the infant is premature or sick. Swad- dling is an effective way to comfort an infant, but overdressing the infant may lead to hyper- thermia and puts the infant at increased risk for SIDS if overheated during sleep (Mayo Clinic Staff, 2011b).

5.8 Developmental Red Flags and Where to Get Help Red flags during infancy should be attended to immediately. As described in this chapter, infants develop quickly and profoundly in the first year. If there is a highly unusual pattern of development or a significant delay in expected progress, time is of the essence. For example, if certain reflexes do not disappear approximately within the typical timetable, it could be a sign of neurological problems. If an infant does not respond or pay attention to sounds or moving objects, the senses may not be functioning properly. If this is the case, progress in the cognitive, motor, social-emotional, and communication domains is likely to be affected. Also, if the infant loses skills rather than gains skills in the various domains, a red flag should be raised. For example, if a child had previously turned to look at an individual calling her name, and this no longer occurs, this could be cause for concern for both the sense of hearing and the infant’s social-emotional development. The child’s pediatrician is often the first profes- sional contacted with any of these concerns. This physician may refer the infant to a devel- opmental specialist or to another health care specialist. If the concern is minor, the specialist may recommend watchful waiting, or early intervention screening and assessment may be the route to take.

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The following red flags should be attended to by the end of the infant’s first 6 months:

• Has poor muscle strength in lifting or controlling the head • Does not respond to noises or lights • Has inadequate weight gain • Has extremely tight or floppy muscles • Uses only one arm or one leg • Does not laugh

Red flags for infants ages 6 months to 1 year include the following:

• Poor eye contact • Makes only a few sounds or none at all • Does not roll over or sit • Does not mouth objects • Does not have object permanence • Does not gesture or point to things

Summary and Resources Infants undergo phenomenal growth and development from birth through 12 months. Infancy is characterized by physical growth that includes increases in weight, height (length), and head circumference. Brain development is quite rapid during infancy. It is grounded in genet- ics and continues to be shaped by experiences, both positive and negative.

Infants make significant progress in the motor, cognitive, communication, and social- emotional developmental domains. By providing for the infant’s basic needs, caregivers set the stage for development in the self-help domain, as well. Motor development during infancy includes reflexes that are either dropped or advanced in the first year. The cephalo- caudal and proximodistal motor patterns are characteristic of gross and fine motor develop- ment in infancy, and they are important for understanding progress in the motor domain. The cognitive progress of an infant is also remarkable, with a significant milestone of acquir- ing an understanding of object permanence. An infant’s cognitive development is interre- lated with advances in the communication and social-emotional domains and is dependent on the five senses.

Communication is central to an infant’s social world and assists in establishing and strength- ening early emotions with the increasing ability to respond and interact within relationships. The communication domain is separated into receptive and expressive skills, both being equally important. The social-emotional domain during infancy focuses predominantly on the need for caregiver attachment and establishing relationships. Infants require caregivers to provide for or attend to their basic needs, including feeding and eating, sleeping, elimina- tion, hygiene, and dressing.

During infancy, certain red flags can be identified in each of the five developmental skill areas and also for the infant’s physical growth. Infants should be monitored carefully so that any areas of concern can receive immediate attention and possible interventions.

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cephalocaudal development Motor devel- opment progression, top down, from the head to the legs.

circumcision The surgical removal of the skin covering the tip of the penis.

echolalia An infant’s imitation of sounds heard in the environment, including sounds from people.

expressive communication The way in which infants express themselves and com- municate to others, including the use of signs, signals, and verbal language.

failure to thrive The characterization of infants whose weight or rate of weight gain is significantly lower than that of other infants, with diminished weight gain due to a medical problem or the result of environ- mental issues such as abuse or neglect, pov- erty, poor eating habits, or parents’ lack of understanding about proper infant nutrition.

fontanels The soft spots of the newborn’s head; found at the front top portion and at the back of the head, with smaller soft areas found in other areas of the skull.

intentional communication Deliberate communication with either actions or vocal- ization with an aim to obtain something or to get something to happen.

limbic system The part of the brain that is responsible for processing experiences and developing control of emotions.

neurons Cells responsible for transmit- ting messages that make up the layers of the brain.

neurotransmitters Chemical messengers, including adrenaline and serotonin, which are found at the ends of neurons. They acti- vate areas of the brain to produce thoughts, emotions, and behavior.

object permanence The cognitive ability to know that objects exist even when they cannot be seen, heard, or touched.

palmar grasp A fine motor grasp that uses a closed palm of the hand when picking up objects.

pincer grasp A fine motor grasp that uses the index finger and thumb when picking up objects.

proximodistal Motor development pro- gression, from the center of the body to the extremities.

pruning The elimination of unneeded syn- apses and neurons in the brain.

receptive communication The ability to understand others’ communication, includ- ing words, sounds, and gestures.

recumbent length A measurement of infant physical development that refers to the length of the infant while lying down.

stunted growth The growth of children who fall below the 5th percentile of the reference population in height for age.

sudden infant death syndrome (SIDS) The sudden death, during sleep, of an infant who appeared to be healthy.

synapses The gaps between neurons through which messages are sent.

umbilical cord The tubing that removes waste and brings nourishment to the fetus from the placenta before birth.

Key Terms and Concepts

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Discussion Questions

1. What are potential consequences of undiagnosed vision and/or hearing impair- ments on infant development? What behaviors might parents observe in their baby if these impairments are present?

2. What sleep recommendations would you discuss with the parents of a newborn child?

3. What aspects of development are measured by pediatricians during an infant’s checkup? Why are these factors important to monitor during infancy?

4. What is the most appropriate course of action if developmental red flags are noted during infancy?

Observational Activities

The following activities encourage opportunities to see child development in action. Arrang- ing occasions to observe or interact with children of various ages creates critical moments to synthesize the learning in this text.

1. Witnessing object permanence; a matter of child’s play: Ask an infant’s caregiver to play peek-a-boo with the child (or with permission, play the game with the infant yourself ). The adult covers and then uncovers his or her face and then makes vari- ous silly faces. Take note of the infant’s age and his or her response to the game. Consider how this activity relates to attachment.

2. Witnessing emerging motor development; take a walk on the wild side: Skilled crawlers are often ready to take those first steps. During this time, the infant enjoys “walking” while using the security of an adult’s hands to maintain balance (like training wheels). Observe a child who is practicing to walk and note the reflex of lift- ing alternate legs and the exercise of shifting balance.

3. Witnessing language development; a sign of the time: Children learn language through oral conversations with caregivers, but even prior to this verbal communica- tion young children may make use of sign language. Many children can understand and elicit signs earlier than they can use words to express their needs. Observe how children use either words or signs to signal what they want. What might such use of nonverbal signs or signals suggest about how nonhearing children develop their com- munication skills?

Web Resources

Center on the Developing Child at Harvard University

http://developingchild.harvard.edu This website has resources on early childhood development including multimedia presenta- tions on brain development and reports and working papers on stress, brain development, and the science of early childhood policies.

American Academy of Pediatrics

www.healthychildren.org This website provides helpful information on care and development of children prenatally to age 21 years; focuses especially on the safety and health of children and tips for parents.

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http://developingchild.harvard.edu

www.healthychildren.org

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Mayo Clinic

www.mayoclinic.org This website provides information on developmental milestones for infants and other cur- rent medical information on health topics.

Centers for Disease Control and Prevention

www.cdc.gov/ncbddd/childdevelopment/positiveparenting/infants.html? This website provides reliable health and safety information on many topics, including life stages and child development.

MedlinePlus

www.nlm.nih.gov/medlineplus/infantandnewborndevelopment.html The website provides information on infant and newborn development, including milestones and other health-related topics.

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www.mayoclinic.org

www.cdc.gov/ncbddd/childdevelopment/positiveparenting/infants.html?

www.nlm.nih.gov/medlineplus/infantandnewborndevelopment.html

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