Contents

SECTION 1 CHILD HEALTH NURSING-I Unit II The Healthy Child

Chapter 6: Growth and Development 57
Unit I Modern Concepts of Child Care  Importance of Studying Growth and
Development 57
Chapter 1: Concepts of Child Care 3  Factors Affecting Growth and
 Introduction to Pediatrics 3 Development 57
 Definition and Concept of Pediatrics 3  Principles/Characteristics of Growth and
 Historical Development of Child Health 3 Development 59
 Philosophy of Child Care 4  Aspects of Growth and Development 60
 Modern Concept of Child Care 5  Theories of Growth and Development 60
 Pediatric Nursing 5  Growth and Developmental Milestones 64
 Cultural and Religious Considerations in Child  Formulas for Anthropometric Assessment 75
Care 6
 Principles of Pediatric Nursing 7 Chapter 7: Needs of Normal Children 77
 Needs of Normal Children Through Stages of
Chapter 2: Child Welfare 9 Development and Parental Guidance 77
 National Policy and Legislation Related to  Nutritional Needs of Infants 78
Child Health and Welfare 9  Baby-friendly Hospital Initiative 84
 National Programs Related to Child Health and  Types and Value of Play and Selection of Play
Welfare 13 Material 85
 Agencies Related to Child Welfare 23  Play Therapy 87
 Rights of Children 25
 Origin of the Rights 25
 The Rights of Children 25 Unit III Nursing Care of a Neonate
Chapter 3: Preventive Pediatrics 28
 Aims of Preventive Pediatrics 28 Chapter 8: Care of a Normal Newborn 93
 Aspects of Preventive Pediatrics 28  Definitions 93
 Levels of Preventive Pediatrics 28  Classification According to Size 93
 Goals of Preventive Care of Children 29  Classification According to Gestational
 Classification of Preventive Pediatrics 49 Age 93
 Preventive Immunization and Cold Chain 30  Classification According to Mortality 94
 Under-Five Clinics/Well Baby Clinics 34  Immediate Physiological Changes in
 Preventive Measures Toward Accidents 35 Newborn 94
 Child Morbidity and Mortality Rates 36  Appraisal of Newborn 95
 Clinical and Neurological Comparison of
Chapter 4: Differences between Children and Adults 41 Preterm and Full-term Infant 102
 Differences Between Illness of Children and  Care of Newborn 103
Adults 41  Immediate Care of Newborn at Birth 103
 Common Illnesses of Children 43  Later and Routine Care of Newborn 104
Chapter 5: Care of Sick Child 45  Neonatal Resuscitation 105
 Hospital Environment for Sick Child 45 Chapter 9: Care of Low Birth Weight 110
 Preparation of Hospital Environment for the  Definitions 110
Child 45  Incidence 110
 Impact of Hospitalization on Child and  Low Birth Weight 110
Family 46  Principles of Management of Low Birth
 Communication Techniques for Children 46 Weight 112
 Role of Nurse in Care of Hospitalized
 Strategies to Reduce Incidence of Low Birth
Children 49
Weight Babies 114
 Principles of Preoperative and Postoperative
 Kangaroo Mother Care 115
Care 47
 Grief and Bereavement 50 Chapter 10: Common Neonatal Disorders 119
 Principles of Preoperative and Postoperative  Common Neonatal Disorders 119
Care 52  Minor Disorders of Newborn/Infant 136
xiv Contents

 Other Symptoms Commonly Present in Chapter 18: Nutritional Deficiency Disorders 267
Neonates 137  Nutrients 267
 Congenital Malformations 139
Nutritional Deficiency Disorders 269
 Genetic Counseling 142  Protein–Energy Malnutrition 269
Chapter 11: Planning and Organization of Vitamin Deficiency Disorders 273
Neonatal Unit 146  Fat-soluble Vitamins 273
 Organization of Neonatal and Pediatric  Water-soluble Vitamins 278
Unit 146
Chapter 19: Disorders of Gastrointestinal System 285
 Introduction to Anatomy of Gastrointestinal
Unit IV Integrated Management of Neonatal System 285
 Upper Gastrointestinal Tract 285
and Childhood Illness  Lower Gastrointestinal Tract 286
 Disorders of Gastrointestinal System 286
Chapter 12: Integrated Management of
Neonatal and Childhood Illness 155 Chapter 20: Disorders of Genitourinary System 329
 IMNCI Guidelines 155 Congenital Renal Malformations 330
 Essential Components of IMNCI Strategy 156  Congenital Defects Related to Kidney/Upper
 IMNCI Case Management Process 156 Urinary Tract 330
 Congenital Defects Related to Bladder and
Urethra 331
Unit V Nursing Management in  Infectious Disorders of Renal System 335
Common Childhood Diseases  Miscellaneous Disorders 339
Chapter 21: Disorders of Neurological System 351
Chapter 13: Disorders of Respiratory System 161  Introduction to Anatomy of Nervous
 Introduction to Anatomy of Respiratory System 351
System 161
 Disorders of Respiratory System 162 Disorders of Central Nervous System 352
 Apnea of Prematurity 162  Infection of Central Nervous System 352
 Acute Respiratory Disorders 163  Disorder of Circulation of Cerebrospinal
 Chronic Respiratory Disorders 170 Fluid 354
 Disorders of Neural Tube Development 357
Chapter 14: Disorders of Endocrine System 175  Seizure Disorder or Epilepsy 362
 Disorders of the Pancreas 175
Chapter 22: Disorders of Musculoskeletal System 367
 Disorders of Thyroid Gland 179
 Disorders of Adrenal Gland 182  Functions of Skeletal System 367
 Disorders of Pituitary Gland 185  Bone Structure 367
 Bone Development and Growth 368
Chapter 15: Pediatric Emergencies 193
 Elements of the Musculoskeletal System 368
 Trauma and Hemorrhage 193
 Initial Assessment and Management 194  Common Musculoskeletal Disorders 368
 Foreign Body 201  Disorders of Spinal Cord 368
 Poisoning 202  Disorders of Hip and Lower Extremities 372
 Drowning 206  Fracture 377
 Burns 207 Chapter 23: Disorders of Skin, Eyes and Ears 386
Disorders of Skin 386
SECTION 2 CHILD HEALTH NURSING-II  Bacterial Skin Infections 386
 Fungal Infections 389
 Viral Skin Infections 391
Unit V Nursing Management in  Parasitic Skin Infections 393
 Other Disorders 393
Common Childhood Diseases
Disorders of Eyes 395
Chapter 16: Disorders of Cardiovascular System 223  Infectious and Inflammatory Conditions of
 Human Cardiovascular System 223 Eyes 396
 Noninflammatory Conditions of Eye 399
Disorders of Cardiovascular System 224
 Disorders of Impairment of Eye Muscles 402
 Congenital Heart Defects 224  Less Common Eye Diseases in Children 404
 Nursing Management of Children with Cardiac
Surgery 234 Disorders of Ears 404
 Physiology of Hearing 405
Chapter 17: Disorders of Hematological System 241  Common Childhood External Ear
 Development of Blood Cells 241 Problems 405
 Functions of Blood 241  Otitis Media (Middle Ear infection) 406
 Disorders of Blood 241  Hearing Loss in Babies 407
 Contents xv
Chapter 24: Common Communicable Diseases 413 Chapter 29: Welfare Services for
 Common Communicable Diseases 413 Handicapped Children 470
 Poliomyelitis 423  Schemes for Welfare of Handicapped 470
Chapter 25: HIV/AIDS in Children 436  Child Guidance Clinics 472
 Magnitude of HIV in Pediatric Population 436 Chapter 30: Child Health Nursing Procedures 474
 Etiology 436  Identification of Critically Ill Child 474
 Mode of Transmission 436  Assessment of Pain in Children 479
 Pathogenesis 436  Drug Doses Calculation 481
 WHO Clinical Case Definition for Pediatric  Calculations for IV Antibiotics 483
AIDS 437  Fluid Calculation 484
 Definition 437  Fluid Preparation 485
 WHO Clinical Staging of HIV in Children 437  Total Parenteral Nutrition
 Clinical Course of Vertically Acquired HIV (Preparation and Administration) 488
Infection 438  Pediatric Fluid Requirement 491
 Diagnostic Evaluation 438  Medication Administration 492
 Management 438  Enteral Feeding 498
 Recommended ART According to NACO for  Nasogastric Tube Insertion and Feeding 499
Children 438  Gastrostomy Feeding 501
 Nursing Management 439  Jejunostomy Feeding 502
 Prevention of Vertical Transmission  Oxygen Therapy 504
(Mother-to-Child Transmission) 439  Nebulization 506
 Prevention of Horizontal Transmission of  Restraints 507
HIV 439  Urinary Catheterization and Catheter
Chapter 26: Management of Common Care 509
 Colostomy Irrigation and Care 512
Behavior Disorders 441
 Care of Baby Under Phototherapy 515
 Definition 441
 Care of Baby Under Radiant Warmer 517
 Types of Behavior Disorders 441
 Care of Baby on Mechanical Ventilator 519
 Habit Disorders 441
 Endotracheal Suction 524
 Speech Disorders 445
 Eating Disorders 445 Appendices  529
 Sleep Disorders 447    Appendix I: Case Scenarios 529
 Personality Disorders 447    Appendix II: Calculation of Fluid Requirement for
Chapter 27: Management of Common Psychiatric Children 532
Problems 452    Appendix III: Formulas for Calculation of Various Tube
 Specific Developmental Disorders 452 Sizes 533
 Pervasive Developmental Disorders 452    Appendix IV: CPR Guidelines by American Heart Association,
 Disruptive Behavior Disorders 453 2020 533
 Anxiety Disorders 454
Index 549
Chapter 28: Management of Challenged Children 457
 Definition 457
 Handicaps 457
 Physical Handicaps 458
 Mental Handicaps 460
 Social Handicaps 467
 6 CHAPTER

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Growth and Development

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Learning Objectives
After completing the chapter the students will be able to:
™ Discuss the importance of studying growth and development

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™ Discuss the factors affecting growth and development
™ Identify the principles/characteristics of growth and development
™ Discuss theories of growth and development
™ Understand the aspects of growth and development
™ Discuss the growth and developmental milestones
™ Learn formulas for anthropometric assessment

INTRODUCTION
O ™ Know what to expect of a particular child at any age.
™ Assess the children in terms of norms for specific stage
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Growth is an essential feature of life of a child that of development, which will help in guiding the children
distinguishes him or her from an adult. The process of into more mature behavior.
growth starts from the time of conception and continues ™ Diagnose undernutrition and overnutrition or any other
until child grows into adult. The terms “growth” and deficiency disorders that affect growth.
“development” are often used together but they represent ™ Ascertain needs of the child at a particular age.
two different facets of the dynamics of change, i.e., quantity ™ Plan and provide comprehensive care to the child.
and quality. The entire course is a dynamic process that ™ Assist parents in environmental modification to keep
encompasses several interrelated dimensions. pace with new emerging needs of children so as to
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™ Growth: Growth refers to an increase in size or mass enable children to achieve optimum growth levels.
of the tissues. It is largely attributed to multiplication
of cells and increase in intracellular substance. It can
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be measured in inches, centimeters, kilograms, and FACTORS AFFECTING GROWTH AND

pounds. So it is a quantitative term. DEVELOPMENT
™ Development: Development specifies maturation
of functions or physiological maturation. The term Growth and development depends not only on one but a
“development” is used to refer progressive increase combination of many factors (Fig. 1). The typical pattern of
in skills and capacity to function. It is a qualitative growth and development is regulated by a complex balance
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change in child’s functioning and is difficult to measure. between heredity or genetic constitution and environmental
Development is the result of maturation and learning. factors. Heredity determines the extent to which growth
™ Maturation: Maturation is an increase in competence and development is possible and environment determines
the degree to which the maximum potential is achieved.
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and ability to function at a higher level, depending on

child’s heredity. It refers to unfolding of human poten-
tialities or hereditary traits, which are carried by genes. I. Heredity/Genetic Factors
™ Heredity: It refers to the genetic constitution of an
IMPORTANCE OF STUDYING GROWTH AND individual, which is established during conception. It
DEVELOPMENT is that property by which offsprings have nature and
characteristics of parents or ancestors. From parents,
The knowledge of growth and development helps the nurse to: the child receives a combination of parental genes. Every
™ Understand the behavior of the child so that the child individual’s supply of genes is given to him at the time of
can be handled intelligently. conception. Color of eyes, hair, facial features, structure
 58 Unit II: The Healthy Child

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Fig. 1: Factors affecting growth and development.
of body, physical peculiarities, blood group, etc., are ™ Prenatal environment: The environment which the
determined entirely by heredity. It is because of hered- fetus gets in utero before birth is known as prenatal

™
to each other. O
ity that members of a family have physical resemblance

Race: Growth potential of children of different racial

groups is different.
environment. This environment provides nutrition and
does gas exchange also. The uterus protects fetus from
adverse effects of external conditions. A substandard or
diseased intrauterine environment has an adverse effect
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™ Sex: Sex of the baby is determined at conception. After on growing fetus. For example, intrauterine rubella
birth, male infant is long and heavier than female infant. infection produces severe reduction in quantity of cells
At the age of 1 year, there is no difference in the length in many organs while toxemia in late pregnancy leads
and weight of male and female infants. During puberty, to significant increase in cell size though the number
growth spurt occurs and boys become taller and heavier of cells is normal. The factors affecting fetal growth are
than girls of their age. as follows:
™ Biorhythm and maturation: Daughters often reach „ Nutritional deficiency in mother: Maternal under
menarche at same age as their mothers had. Also the nutrition and anemia leads to intrauterine growth
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length of menstrual cycle is same as that of mother. retardation and consequently small size of fetus.
™ Genetic disorders: Growth and development are „ Obstetric disorders : Obstetric disorders like
adversely affected by certain genetic disorders. These pregnancy induced hypertension, preeclampsia,
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disorders are of two types: multiple pregnancy, and malposition of fetus

a. Chromosomal abnormalities like Turner’s produces fetal growth restriction.
syndrome and Down syndrome, which cause „ Metabolic disorders in mother : Disorders of
growth retardation. metabolism like diabetes mellitus leads to large
b. Gene mutations may lead to metabolic defects size of fetus.
like galactosemia. „ Infections: Maternal rubella infection occurring
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during first trimester of pregnancy results in

II. Environmental Factors congenital malformation in fetus. Children with
Although each human being at birth has a genetically birth defects cannot grow at an optimal rate. Other
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determined physical, mental, and biochemical potential, maternal infections like syphilis, hepatitis B, human
but this potential may or may not be reached because of immunodeficiency virus (HIV), Cytomegalovirus
environmental influences. Stimulation for development of inclusion, toxoplasmosis, etc., may be transmitted
innate abilities comes from the environment, which may be to the fetus, which may arrest or retard the growth
favorable or unfavorable. of fetus.
„ Administration of certain drugs: Consumption of
certain drugs like thalidomide by mother during
first trimester of pregnancy adversely affects embryo
and leads to birth defects. These drugs are called
teratogenic agents.
 Chapter 6: Growth and Development 59
„ Influence of maternal hormones: of many nutritional substances and antibodies present
– Thyroxine: Human fetus secretes thyroxine from in colostrum, which makes these children susceptible
12th week of gestation. Thyroxine deficiency to infections thereby affecting growth.
in mother retards skeletal maturation in fetus. ™ Emotional factors: Children from broken homes and
Maternal myxedema results in hypothyroidism orphanages do not grow and develop at an optimal rate.
in fetus. Anxiety, insecurity, lack of emotional support, and love

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– Insulin: Insulin stimulates fetal growth. In from the family affects the neurochemical regulation
mothers with diabetes, fetus is usually large with of hormones, which affect growth and development of
excessive birth weight. As maternal blood sugar children. On the other hand, parents who had happy

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level is high, fetal blood sugar is also elevated. childhood and have cheerful personality transmit these
This leads to hyperplasia of islet cells of fetal characters to their children.
pancreas leading to excessive insulin secretion
resulting in macrosomia.
™ Postnatal environment: The environment that the baby PRINCIPLES/CHARACTERISTICS OF GROWTH
gets after birth is known as postnatal environment. This AND DEVELOPMENT
environment determines the pace and pattern of growth

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Gessel (founder of clinical child psychology) has concluded
and development. Postnatal environmental factors
from genetic studies of children—“although no two children
affecting growth and development are:
are alike, all normal children tend to follow a general
„ Nutrition: Growth of children suffering from protein-
sequence of growth”. There are certain basic predictable
energy malnutrition, anemia, and vitamin deficiency
characteristics or principles of growth and development,
diseases (like rickets) is severely affected. Also
which are as follows:
overeating and overnutrition leads to obesity.
1. Development is similar for all: All children follow

causes of growth impairment. Systemic infections

and parasitic infestations usually decrease the
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„ Infections and infestations: Persistent or recurrent
diarrhea and respiratory tract infections are common
similar pattern of development with one stage leading
into the next. Every child passes through similar
stages. For example, baby learns to stand before he
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walks, similarly, baby draws circle before a square.
velocity of growth.
2. Development proceeds from general to specific: In
„ Chemical agents: Consumption of androgenic
motor as well as mental responses, general activity
hormones accelerates skeletal growth.
always precedes specific activity. Before birth, fetus
„ Trauma: Fracture of end of bone, damages the
moves the whole body but is incapable of making
growing epiphysis and thus hampers skeletal growth.
specific movements. Generalized body movements
Head injury may cause brain damage and seriously
occur before fine motor control is achieved. For
jeopardize mental development of the child.
example, first the infant moves whole body in the
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womb and later starts moving his hands. Similarly,

III. Other Factors infants move hands first and then learn using fingers.
™ Socioeconomic condition: The environment of 3. Development is continuous: Development is a
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children born in lower socioeconomic groups is usually continuous process, starting from conception and
less favorable than those in middle and upper groups. ending at death. It is continuous but sometimes rapid
The parents with poor financial condition usually and at times slow. For example, speech in a child does
cannot take proper care of their children, as they do not develop overnight, the child coos, gurgles, and
not have money to buy essentials of health and diet. makes sounds first and then slowly and gradually
Poverty, crowded, and unhygienic living conditions lead learns words and then language develops.
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to retardation of growth and development in children. 4. Development proceeds at different rates: Growth
™ Cultural influences: Culture influences the child and development is a continuous process, which is
rearing and infant feeding practices in community. rapid at times and at times slows down. Rapid growth
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There are many cultural taboos against consumption occurs during fetal life and infancy and it slows down
of particular foodstuffs. This affects the nutritional during school age. A growth spurt occurs in puberty
status and growth of the children. For example, some and early adolescence, but it slows down during
communities are strictly vegetarian and do not consume adulthood and old age.
egg, meat, etc. The children of these communities do not 5. There is correlation in growth and development:
get proteins of high biologic value due to which their Correlation in physical and mental abilities is
growth may be retarded. Similarly in some communities, especially marked. There is a marked relationship
colostrum is not fed to the child as it is considered between sexual maturation and patterns of interest
impure yellow milk. This practice devoids the children and behavior.
 60 Unit II: The Healthy Child

6. Development comes from maturation and learning: ASPECTS OF GROWTH AND DEVELOPMENT
Sudden appearance of certain traits that develop
through maturation is quite common. For example, a Growth and development have the following aspects:
baby may start walking overnight. Behavioral changes
occur at the time of puberty suddenly without any
reason. Learning comes from exercise and efforts on

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part of an individual. Unless the child had opportunity
for learning, many of his hereditary potentials will never
reach their optimum development. For example, a child

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may have aptitude for music because of his superior
neuromuscular organization, but if he is deprived of
opportunities for practice and systematic training, he
will not reach his maximum potential. Intrinsic growth
is a gift of nature. Innate capacities should be stimulated
by positive environmental factors.
7. There are individual differences: Although pattern
THEORIES OF GROWTH AND DEVELOPMENT

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of development is similar for all children, each child
follows a predictable pattern in his own way and at A. Growth
his own rate. Each child with his unique heredity and
nature (environment) will progress at his own rate ™ Biologic growth: Changes in body result from growth
in terms of size, shape, capacity, and developmental of different parts of body. The National Center for
status. Health Statistics (NCHS) made a massive survey of
8. Early development is more significant than later
development: If the foundation of a building is O
strong, the building will be strong. Similarly, favorable
conditions during infancy lead to growth of child
characteristics of growth—length or height, weight,
and head circumference. These are the parameters for
assessing growth in children.
„ Length or height: Length or height increases from
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into a healthy adult. If the conditions during prenatal birth to maturity. Rapid increase in height occurs
period and postnatal period are unfavorable, there is during infancy and adolescence. The average length
a damaging effect on later growth and development of a newborn is 45–50 cm and it increases at the rate
of the child. of 2–2.5 cm/month for first 6 months and then 1.25
9. Development proceeds in stages: Development is cm/month during next 6 months. At the age of 1 year
not abrupt, it proceeds in stages that are as follows: length is 75 cm. The height of infant doubles at the
„ Prenatal period: From conception to birth age of 4 years and triples at 13 years.
„ Neonatal Period: Birth to 4 weeks „ Weight: Weight is the best gross index of health and
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„ Infancy: 4 weeks to 1 year nutritional status of children. The average weight

„ Toddler: From 1–3 years of a newborn is 2.5–3.5 kg. There is initially loss of
„ Preschool: 3–6 years (early childhood) weight during first 10 days of life due to adjustment
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„ School age: 6–12 years (late childhood) to extrauterine life, inadequate feeds, and digestive
„ Adolescence: From puberty to beginning of adaptation. After 10 days of life, baby gains about 30
adulthood (13–18 years) g weight per day for 5–6 months so weight doubles
10. There are predictable patterns of growth and at 6 months of age and becomes about 5–6 kg.
development: Both during prenatal and postnatal Thereafter weight gain becomes 15 g per day during
period, growth and development follow two patterns: next 6 months. So at the age of 1 year weight becomes
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„ Cephalocaudal triple of birth weight (about 7.5–8 kg). At the age of

„ Proximodistal 2½ years weight becomes four times the birth weight
According to cephalocaudal pattern, development that is 10–12 kg.
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spreads over the body from head to foot. This means „ Head circumference: The head circumference
that improvement in structure and functions of the body is an important measurement since it is related
comes first in head region, than in trunk, and lastly the legs. to intracranial volume. An increase in head
According to proximodistal pattern, development proceeds circumference indicates rate of brain growth. At
from near to far, i.e., from central axis of body towards the birth, the normal head circumference is 33 cm
periphery or extremities. During prenatal period, the head approximately and it increases at the rate of about
and trunk develop fully and then the limb buds appear. ½ inch per month during first 6 months and then at
Slowly the arms lengthen, followed by forearms and lastly the rate of ¼ inch per month during next 6 months.
the fingers. Functionally also, the baby starts using his arms The head circumference is 40 cm at 3 months and
before his hands and fingers. 45 cm at 1 year of age.
 Chapter 6: Growth and Development 61
„ Chest circumference: The chest is barrel shaped solve those problems. Infants are more expert at solving
at birth and the anteroposterior and transverse problems than we realize. Intellectual development occurs
diameters are equal. Gradually the transverse from infancy onwards as behavior changes, due to:
diameter increases, causing width to become ™ Maturation of innate capacities
greater than the anteroposterior diameter. At birth ™ Conditioning (learning by association of a stimulus with
chest circumference is 31 cm and at the end of 1 response)

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year head circumference becomes equal to chest ™ Reinforcement of appropriate behaviors
circumference, thereafter only chest circumference ™ Imitation of behavior of others
increases. ™ Insight

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™ Motor growth: Motor development depends on Although potential mental ability is inherited and fixed
maturation of muscular, skeletal, and nervous system. at birth, the rate and extent of its development are very
The motor development follows cephalocaudal and much influenced by child’s environment. As the structure
proximodistal pattern. Motor development is of two of nervous system grows, changes can be seen in infant’s
types: mental reactions. These reactions indicate progression
„ Gross motor: Gross motor development leads to from the ability to respond to simplest stimuli towards
functioning in complex ways.

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acquisition of increasing mobility and independent
movements. Gross motor activities include turning,
sitting, standing, and walking. Piaget’s Theory of Intellectual or Cognitive Development
„ Fine motor: Fine motor development leads to
According to Piaget (Gruber Voneche, 1977) maturation and
acquisition of motor dexterity like use of hand and growth have certain sign posts. Although, newborn baby
fingers, palmar grasp and release, pincer grasp, etc. perceives the world as a vague mass, the child gradually
™ Sensory growth: Although sensory system is functional
at birth, the child gradually learns the process of
associating meaning with a perceived stimulus. Most O
active senses at birth are sense of taste and smell. As
develops an integration or coordination of various sensory
inputs from touch, taste, smell, sight, and sound into an
organized and objective understanding of reality. Also the
child does not understand that objects which cannot be
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myelinization of nervous system occurs, the child is able seen still exist. The adult knows that house is there, even
to respond to specific stimuli. The visual system is last when the house is not present to be observed. To a young
to mature, at about 6–7 years of age. child the concept of constancy comes slowly.
The ability to use symbols to represent reality is another
B. Development important stage in development. The use of symbols leads
to language development in child.
Many theories have been devised to study development of
A child less than 7 years of age can focus on only one
different aspects in children.
aspect of a situation and cannot relate other information
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™ Intellectual development theory by Jean Piaget

and observations to it. For example, an elder sibling who
™ Moral development theory by Jean Piaget and Kohlberg
puts on a horrifying mask can easily frighten a young
™ Psychosocial development theory by Eric H Erikson
child because the child cannot understand that, even
™ Spiritual development theory by James W Fowler
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though dressed differently, the elder sibling is still the

™ Sexual development theory by Sigmund Freud
same person. Advanced cognitive functioning is required
™ Emotional development theory by Eric H Erikson
to understand this.
For advanced cognitive functioning to occur, child must
Intellectual Development pass through various stages of development.
Although tests of intelligence and mental development According to Piaget, four major stages of development are:
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have been standardized, there is no way of measuring a. Sensorimotor stage (0–2 years): In this stage, children
genetically carried trait of intelligence. Mental development are mainly concerned with learning about physical
is demonstrated in problem solving and in general objects.
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understanding of what to do in a given situation. It is b. Preoperational stage (2–7 years): In this stage, they
important to let children solve problems that they can, by are preoccupied with symbols in language, dreams, and
themselves and to teach them how to solve the problems fantasy.
that are within their abilities but for which they lack the c. Concrete operational stage (7–11 years): In this stage,
necessary experience and practice. Also problems which are they move into abstract world mastering numbers,
too difficult for them should be solved for them. relationships, and reasoning.
Infants at first are confronted with physical problems d. Formal operational stage (11–15 years): In this stage,
and the normal reflex actions of their bodies help them to the children have purely logical thoughts.
 62 Unit II: The Healthy Child

Moral Development Psychosocial Development

Piaget and Kohlberg gave their theories discussing the The theor y of Erikson Concerning “Psychosocial
complicated process by which values are formed, how Development” states that emotional or personality
they affect behavior, and how they are changed through development is a continuous process, which has the
experience. following stages:

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i. Trust versus mistrust (birth to 1 year—infant):
Kohlberg’s Theory of Moral Development Infants learn to trust the adults, usually the parents
who care for them and are sensitive to their needs. A
Kohlberg believed that development of moral reasoning negative outcome of the period of infancy is the sense

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occurs step by step in sequence. Kohlberg postulated six of mistrust, which develops if the basic needs of infant
stages of potential moral development, organized within are not met.
three levels—preconventional morality, conventional ii. Autonomy versus shame (1–3 years—toddler):
morality, and postconventional morality. Infants develop from clinging, dependent creatures
Level 1: Preconventional morality (ego centricity): into individuals with mind and will of their own.
Children make moral judgments only on the basis of what The three major psychosocial tasks of toddlerhood

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will bring them reward (a right act) or punishment (a wrong are gaining self-control, developing autonomy, and
act). This level is divided in three stages. increasing independence. If the child succeeds in
a. Stage 0 (0–2 years): In this stage the child feels that good development of autonomy, he develops feeling of
is what I like and want and bad is what hurts. self-esteem, but if he does not succeed, he doubts his
b. Stage 1 (2–3 years): This stage is punishment-obedience abilities and develops a sense of shyness and shame.
oriented. The older toddler and preschool children iii. Initiative versus guilt (3–6 years—preschool
believe that if they are not punished, the act was right
and if they are punished the act was wrong.
c. Stage 2 (4–7 years): Instrumental Hedonism and
Concrete Reciprocity—In this stage child considers
O child): This is a period of very energetic play and
active imagination. The child can develop a sense
of accomplishment and satisfaction in his or her
activities. As the child oversteps his or her limits, he
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those actions right that meet their own needs or those or she experiences a feeling of guilt.
of others. They carryout rules to satisfy themselves or iv. Industry versus inferiority (6–12 years—school age
because what others might do or think if they do not child): Children in this age have a strong sense of
carry them out. duty. Their energy is channeled into activities such as
Level 2: Conventional morality: In this stage, children school projects, sports, and hobbies. These concrete
think that correct behavior is that, which those in authority endeavors become the child’s work and bring a sense
approve and accept. In this level, there is one stage. of accomplishment. If the children are not able to
d. Stage 3 (7–9 years): Orientation to interpersonal achieve a sense of industry, feeling of inferiority may
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relationships occur in this age. Children of early school develop.

age are becoming socially sensitive, so they try to do v. Identity versus role diffusion (12–15 years—
actions which help them to gain approval in their family, beginning of adolescence): Two major tasks for
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peers, and teachers. adolescents are figuring out who they are and what
Level 3: Postconventional morality (adolescents and is their place in the world. Success in this period
adults): Adolescents make choices on the basis of makes the individual well adjusted, stable, and
principles that are taught to them about acceptable mature. Individuals who have not experienced any
behaviors. Whatever actions conform to these principles active exploration nor made a commitment to any
are considered right. This level includes two stages. occupation, develop identity diffusion.
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e. Stage 4: Higher laws and conscience orientation: vi. Intimacy versus self-absorption (late adolescence):
Adolescents follow culturally appropriate values and In this stage, the adolescents focus on forming
perform actions that benefit the society involving good intimate relationships with others. They develop
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of all. a sense of intimacy with peers. Failure to establish

f. Stage 5: Universal ethical principle orientation: This such intimacy results in psychological isolation, i.e.,
is the highest level of moral values and standards. keeping relations without warmth.
Adolescents develop internalized standards and self-
actualization. Spiritual Development
According to Kohlberg, moral sense is not acquired
by simply following the rules of the society. It is acquired Religious beliefs are based on theories of atheism or
through an internal and personal series of changes in the agnosticism. Fowler (1974, 1980, 1983) has given “Stage
attitude. theory of faith” which parallels the formal developmental
 Chapter 6: Growth and Development 63
process proposed by Piaget and Kohlberg. According to conflict arises, wherein a boy desires for his mother but
Fowler, faith is a universal feeling that is expressed through has a fear of castration by rival father. In this stage, the
beliefs, rituals, and symbols, specific to religious traditions. boys fixate on the mother as a sexual object (known as
It is multidimensional and a way of learning about life. As Oedipus Complex) but the child eventually overcomes
described by Fowler, faith is an ongoing process in which and represses this desire because of its taboo nature.
individuals form and reform their way of seeing the world. Freud attempts to formulate a comparable process for

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People may acquire their religious beliefs and preferences in girls fixating on fathers (known as Electra Complex).
childhood and may deepen those convictions as their faith During this stage, the child loves parents of opposite
develops or they may change religious beliefs in adulthood. sex and takes them as provider of sensual satisfaction.

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Stage I: Primal faith (infancy): Paralinguistic and ™ Latency stage (School age, 6–12 years): This is
preconceptual, this stage embodies trust between parents repressive or dormant stage of psychosexual
and infants. Parents and child form mutual attachment and development.
progress through a period of give and take. The primary ™ Genital stage (About 12 years to adulthood): During
caregiver provides the infant and young child with a variety this stage, developing human matures from pleasure
of experiences that encourage the development of mutual seeking infant into sexually mature adult who is free to
trust, love, and dependence progressing to autonomy. enter heterosexual relationships.

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Stage II: Intuitive—projective faith (farly childhood age
3–7 years): This stage is characterized by child forming long Development of Language and Speech
lasting images and feelings. Imagination, perception, and The ability to communicate is a significant factor in
feelings are the mechanisms by which child explores and child’s intellectual, emotional, and social development.
learns about the world at large. Broadly speaking, the term language development refers
Stage III: Mythic—literal faith (childhood and beyond):
Beginning at about age of 7 years, children’s beliefs are
derived from perspective of others. During this stage, theyO
are able to differentiate their thinking from that of others.
to increasing quantity, range, and complexity of speech
over a period of time. Language is a complex system of
grammatical semantic properties and the actual utterance
of language is speech. Children are able to understand
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Stage IV: Synthetic—conventional faith (adolescence language before they are able to speak it.
and beyond): In this stage, a person’s experience extends Children are born with physiologic ability to speak,
beyond the family to peers, teachers, and other members if they have normal oral and nasal cavities and speech
of society. As a result of cognitive abilities, the individual control center in brain. They can learn to speak if they
becomes aware of emotions, personality patterns, ideas, have intelligence and motivation and are stimulated by
thoughts, and experiences of self and others. As a result, other people’s speech in their environment.
the individual has a cluster of values and beliefs concerning Prelingual speech is same for all children, which
others. includes reflex vocalization, babbling, imitation of sounds,
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and finally verbal utterances. The rate of language and

speech development and use of grammatical rules depends
Psychosexual Development on child’s level of intelligence.
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In accordance with the view that basic human motivation The child’s articulation or ability to pronounce words
is sexual drive, Sigmund Freud developed a psychosexual correctly develops along with language ability. Auditory
theory of human development from infancy onwards, discrimination or ability to differentiate sounds is also very
divided into series of psychosexual stages. Freud named important aspect of speech development. Children are able
these stages asoral, anal, phallic, latency, and genital. Each to recognize correctly articulated sounds before they can
stage focuses on gratification of libido through a particular pronounce them. Vocabulary or semantic development
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erogenous zone of the body. If a child does not successfully progresses from infancy throughout life. By 10–12 months
complete a stage, he or she would develop a fixation that of age, the infant usually says the first word having
would later influence adult personality and behavior. meaning. Vocabulary development slows down while the
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™ Oral stage (Infancy, the first year of life): This is the child is learning to walk. The most dramatic vocabulary
first stage exemplified by infant’s pleasure in nursing. development takes place between 18 months to 3 years
Gratification of needs center around feeding. of age.
™ Anal stage: (Toddler period, 2–3 years): This stage In general, the firstborn child in the family develops
revolves around interest in body functions and language and speech earlier than those born later, probably
gratification of needs is by retaining and expelling faces. because of attention received from adults. Girls learn
™ Phallic stage (Preschool period, end of third year language and speak earlier than boys, probably because
of age up to 5 years): In this stage, the site of greatest boys have slower rate of neurophysiologic maturation. The
sensual pleasure is genital region. In this stage oedipal development of language may be impaired or retarded if
 64 Unit II: The Healthy Child

there are congenital defects of oral or nasal cavity, maternal

deprivation, deafness, mental retardation, and emotional
problems.

GROWTH AND DEVELOPMENTAL MILESTONES

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Milestones are the accomplishment of different biological
functions at an anticipated age, with a margin of few months
on either side.

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The developmental milestones of children include following
Fig. 2: Flexed posture of newborn.
aspects:
™ Physical development
™ Motor:
„ Gross
„ Fine

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™ Sensory development
™ Cognitive development
™ Language development
™ Social development

From Birth to 1 Year (Infants)

Newborn
™ Physical growth
O Fig. 3: Head lag when pulled to sit (1 month age).
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„ Weight: Average birth weight of newborn is 2.5 kg.
It decreases by 10% in first 10 days of life and then „ Notices faces and bright objects but only if they are
increases at the rate of 500–600 g per month during in line of vision.
first 6 months. ™ Language development
„ Length: At birth, the length of newborn is 45–50 „ Startles to loud noises.
cm. It increases approximately 2–2.5 cm per month „ Responds to human voice.
during first 6 months. „ Makes comfort sounds during feeding.
„ Head Circumference: At birth, it is approximately „ Begins to coo.
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33–35 cm and increases at the rate of 1.5 cm per ™ Newborn senses

month during first 6 months. „ Touch
„ Chest circumference: It is about 31–33 cm. „ Vision
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„ Pulse rate is 130 + 20 beats/minute. „ Hearing

„ Respiration is 35 + 10 breaths/minute. „ Taste
„ Blood pressure is 80/50 + 20/10 mm Hg. „ Smell
„ Reflexes: The baby has well-developed sucking,
Touch
rooting, swallowing, and extrusion reflex. Baby also „ It is the most highly developed sense.
has Moro’s, tonic neck, and crossed extensor reflex. „ It is mostly at lips, tongue, ears, and forehead.
™ Motor development
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„ The newborn is usually comfortable with touch.

„ Gross motor
– Lies in flexed position with hands clenched
Vision
„ Pupils react to light.
(Fig. 2).
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„ Bright lights appear to be unpleasant to newborn

– Turns head when in prone position.
– Head lags behind when baby is pulled up from
infant.
„ Follow objects in line of vision.
supine to sitting position (Fig. 3).
„ Fine motor Hearing
– Grasp reflex is strong. „ The newborn infant usually makes some response
– Baby can grasp an object placed in hand but to sound from birth.
drops it immediately. „ Ordinary sounds are heard well before 10 days of life.
™ Sensory development „ The newborn infant responds to sounds with cry or
„ Protective blinking reflex is present. eye movement, cessation of activity, and/or startle
„ Indefinite stare at surroundings. reaction.
 Chapter 6: Growth and Development 65
Taste ™ Sensory development
Well-developed as bitter and sour fluids are resisted „ Turns head and looks in same direction to locate
while sweet fluids are accepted. sound.
„ Blinks at objects that threaten the eyes.
Smell
„ Beginning of ability to coordinate various sensory
Only evidence in newborn infant’s search for the nipple,
stimuli.
as he smell breast milk.

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™ Language development
„ Cries less
2 Months „ Shows pleasure in making sound

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„ Chuckles and coos.
™ Physical development
™ Social development
„ Posterior fontanel closes at 6–8 weeks age.
„ May laugh loud.
„ Tears start appearing.
„ Looks in direction of speaker.
„ Drooling begins.
„ Obligate (preferential) nose breathers.
™ Motor development 4 Months

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„ Gross motor
™ Physical development
– Less fixed prone position—arms flexed, hip flat,
„ Drooling indicates appearance of saliva.
and legs extended.
„ Tonic neck and rooting reflex disappears.
– Lifts head almost to 45° above flat surface when
™ Motor development
lying prone.
„ Gross motor
„ Fine motor
– Holds head erect and steady when placed in
– Hands may be open.

™
– Holds a rattle when placed in hand.
Sensory development O
„ Turns head to side when sound occurs at ear level.
sitting position.
– Sits for short time with adequate support.
– Lifts head and shoulders at 90° when prone and
looks around (Fig. 4).
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„ Eyes follow moving objects and persons nearby.
– Head lag disappears when pulled to sit.
„ Visual acuity is hyperoptic.
„ Fine motor
™ Language development
– Brings hands together in midline and plays with
„ Laughs and squeals.
fingers.
„ Crying becomes differentiated, varying with reason
– Reaches for objects.
for crying, e.g., hunger, sleep, pain, etc.
™ Sensory development
„ Utters single vowel sounds such as “ah” and “eh”
„ Follows objects to 180°.
™ Social development
„ Fairly good binocular vision.
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„ Smiles to mother/caregiver.
„ Beginning of hand-eye coordination.
„ Knows that cry will bring attention.
™ Language development
„ Utters two syllable vowel sounds.
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3 Months „ Can vocalize consonants like “m, b, and g”.

„ Responds differently to pleasant and angry voice.
™ Physical development
Flexion posture is reduced.
„
Grasping, crossed extensor and Moro’s reflex
„
disappears.
„ Landau reflex appears.
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™ Motor development
„ Gross motor
– Able to lift head to 90° when in prone position.
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– Able to hold head erect but head still bobs

forward.
– Rolls over from back to side.
„ Fine motor
– Can grasp a toy but lacks firm hold.
– Hands open and closed loosely.
– Carries objects and hands to mouth at will.
Fig. 4: Lifts head to almost 90° in prone position at (4 months).
 66 Unit II: The Healthy Child

™ Social development
„ Initial social play by smiling.

5 Months
™ Physical development

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„ Weight almost double of birth weight.
„ Can breathe through mouth when nose is obstructed.
™ Motor development

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„ Gross motor
– Sits with slight support.
– Holds back straight when pulled to a sitting
position.
– Pulls feet up to mouth when in supine.
– Rolls from back to abdomen.
„ Fine motor Fig. 5: Sits leaning forward with support of hands

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– Attempts to “catch” dangling objects with two (6 months of age).
hands.
– Begins use of forefinger and thumb in a pincer – Begins to transfer objects form one hand to
grasp. another.
– Tries to obtain objects beyond reach. – Manipulates small objects.
– Can hold one object while looking at another. – Bangs objects that are held.
™ Sensory development
„ Looks in direction of sound made below ear.
„ Stops crying in response to music.
„ Visual acuity is 20/20.
O ™ Sensory development
„ Localizes sound made above ear level.
„ Enjoys more complex visual stimuli.
„ Moves in order to see an object.
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™ Language development ™ Language development
„ Responds to his/her name. „ Babbling
„ Vocalizes displeasure when desired object is taken „ Vocalizes monosyllable like ma, da, and ba.
away. „ Recognizes familiar words.
„ Begins to mimic sound. „ Talks to own image in mirror.
„ Cries on seeing strangers. ™ Social development
™ Social development „ Recognizes parents.
„ Smiles to self in mirror.
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„ Extends arms to be picked.

„ Differentiates strangers from family members.

7 Months
6 Months
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™ Physical development
™ Physical development „ Parachute reflex appears.
Weight gain is about 300–400 g/month during next
„ „ Ultimate color of iris is established.
6 months. „ Mashes food with jaws.
„ Length increases at the rate of 1.25 cm/month. ™ Motor development
„ Head circumference increases at the rate of 0.5–1 „ Gross motor
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cm/month. – Lifts head as if trying to sit-up when in supine

„ Pulse rate is 120 + 20 beats/minute. position.
„ Respiration is 31 + 9 breaths/minute. – Rolls more easily from back to abdomen.
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„ Blood pressure is 90/60 + 28/10 mm Hg. – Sustains all weight on feet when held in standing
„ Teeth eruption starts with lower two central incisors. position (Fig. 6).
™ Motor development – Early stepping movements.
„ Gross motor „ Fine motor
– Sits leaning forward on both hands (Fig. 5). – Holds two toys together.
– Moves from place to place by rolling. – Transfers a toy from one hand to another.
– Back is straight when sitting in high chair. – Bangs objects that are held.
„ Fine motor ™ Sensory development
– Can grasp at will. „ Has preference in taste for food.
– Drops one object when offered another. „ Depth perception is beginning to develop.
 Chapter 6: Growth and Development 67

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Fig. 6: Whole weight on legs when supported (7–8 months). Fig. 7: Creeping position (9 months).

™ Language development ™ Motor development

Recognizes own name.
„ „ Gross motor

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Responds with gestures to words such as “come”.
„ – Sits down.
Vocalizes “baba” and “dada”.
„ – Drinks from cup or glass with help.
™ Social development – Crawls and creeps (Fig. 7).
„ Shows fear of strangers. – Holds own bottle.
„ Closes lips tightly when disliked food is offered. „ Fine motor
– Rings bell.
– Holds bottle and places nipple in mouth when
8 Months
™ Physical development
„ Begins to show pattern in bladder and bowl
O wants it.
™ Sensory development
„ Head turns directly to source of sound.
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elimination. „ Recognizes by looking or moving towards familiar
„ Eruption of upper central incisors. objects when named.
™ Motor development ™ Language development
„ Gross motor „ Stops activity in response to “NO”.
– Pulls to standing position with help. ™ Social development
– Raises self to sitting position. „ Dislikes face wash.
– Palmar grasp disappears. „ Cries when scolded.
„ Fine motor „ Wants to please caregiver.
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– Holds two objects while looking at third.

– Releases objects from hands at will.
– Uses index finger and thumb like pincers. 10 Months
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– Feeds self with finger foods.

™ Physical development
– Drinks from cup with assistance.
„ Drooling stops.
™ Sensory development „ Macula is well-developed and fine visual
„ Depth perception is developing.
discrimination can be made.
„ Recognizes familiar words and sounds.
™ Motor development
™ Language development „ Gross motor
„ Begins to understand meaning of “NO”.
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– Walking skill development continues.

„ Continues syllable “dada and mama” without
– Creeps and cruises well.
specific meaning. – Does not want to lie down unless sleepy.
„ Babbles to produce consonant sounds.
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– Makes stepping movements forward when two

„ Vocalizes to toys.
hands are held.
™ Social development „ Fine motor
„ Fear of strangers.
– Fine pincer grasp of tiny objects (Fig. 8).
„ Dislike dressing and diaper change.
– Brings hands together and plays.
„ Separation anxiety develops.
– Bangs two cubes together.
™ Sensory development
9 Months „ Tilts head backward to see up.
™ Physical development „ Localizes sound from above or below ear.
„ Eruption of upper lateral incisors. „ Searches for a lost toy.
 Chapter 6: Growth and Development 75

15–16 Years FORMULAS FOR ANTHROPOMETRIC ASSESSMENT

™ Sperm matures and can cause pregnancy.
Age in months + 9
™ Majority of growth spurt is complete. Weight of infant from 3 -12 months =
2
16–17 Years Weight of 2–8 years old = (Age in years × 2) + 8 = ….. kg

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(Age in years  7) - 5
™ Chest and shoulders fill out. Weight of 7  12 years old = –5
2
™ Facial and body hair becomes heavier.
™ Acne occurs. Height of 2–12 years old = (Age × 6) + 77 cm

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REVIEW QUESTIONS
QI. Fill in the Blanks:
i. The average weight of a newborn is _________________.kg.

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ii. The average length of a newborn is _________________.cm.
iii. The founder of clinical child psychology is _________________.
iv. Human fetus starts secreting thyroxin at gestational age of _________________.
v. Toilet training must begin at the age of _________________.months.
vi. Breastfeeding must be initiated within _________________ hour of normal delivery.
vii. An increase in mass or size of the tissues is known as _________________.

xi.
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viii. ___________ refers to progressive increase in skills and capacity to function.
ix. _________________ refers to an increase in competence and ability to function at a higher level.
x. The length of the baby increases at the rate of _________________ cm per month for first 6 months.
_________________ is the best gross index of health and nutritional status of children.
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xii. After 10 days of life, baby gains about _________________ grams weight per day for 5–6 months.
xiii. Weight of the baby becomes triple of the birth weight at an age of _________________.
xiv. The height of the child doubles at the age of _________________ years and triples at _________________
years.
xv. At the age of _________________ head circumference becomes equal to chest circumference.
QII. Multiple Choice Questions:
i. The normal head circumference at birth is:
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a. 33 cm b. 39 cm
c. 36 cm d. 31 cm
ii. The normal chest circumference at birth is:
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a. 35 cm b. 31 cm
c. 32 cm d. 37 cm
iii. The vision matures at the age of about:
a. 4–5 years b. 11–12 years
c. 10–11 years d. 6–7 years
iv. Anterior fontanel closes at the age of:
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a. 18–24 weeks b. 6–8 weeks

c. 18–24 months d. 6–8 months
v. Tears start appearing at the age of:
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a. 1 months b. 2 months
c. 3 months d. 4 months
vi. Baby pulls to standing position with minimum support, by the age of:
a. 8 months b. 6 months
c. 12 months d. 9 months
vii. Teeth eruption starts at the age of:
a. 6 months b. 8 months
c. 5 months d. 7 months