child devlpt

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    </B><A HREF="index.htm" TARGET="_top" TITLE="pediatryPART I"><U><B>home</B></U></A></div> <div> <A HREF="id31.htm" TARGET="_top" TITLE="PEDIATRIC PEARLS FOR THE USMLE"><U>PEDIATRIC PEARLS FOR THE USMLE</U></A>   |   <A HREF="id48.htm" TARGET="_top" TITLE="pearls pediatry 2"><U>pearls pediatry 2</U></A>   |   <A HREF="id18.htm" TARGET="_top" TITLE="general"><U>general</U></A>   |   <A HREF="id34.htm" TARGET="_top" TITLE="appendiceal colic"><U>appendiceal colic</U></A>   |   <A HREF="id35.htm" TARGET="_top" TITLE="ATOPIC DERMATITIS"><U>ATOPIC DERMATITIS</U></A>   |   <A HREF="id19.htm" TARGET="_top" TITLE="Stuttering"><U>Stuttering</U></A>   |   <A HREF="id20.htm" TARGET="_top" TITLE="enuresis"><U>enuresis</U></A>   |   <A HREF="id21.htm" TARGET="_top" TITLE="Conduct Disorder in Children and Adolesc"><U>Conduct Disorder in Children and Adolescents </U></A>   |   <A HREF="id22.htm" TARGET="_top" TITLE="Specific Growth Curve Deviations "><U>Specific Growth Curve Deviations </U></A>   | 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BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 ><NOBR><div> TRIMEST./QUART. 1</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="220"><div> TRIMEST./QUART. 2</div> </tD> <tD VALIGN=CENTER><NOBR><div> TRIMEST./QUART. 3</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="306"><div> TRIMEST./QUART. 4</div> </tD> <tD VALIGN=CENTER WIDTH="417"><div> TRIMEST./QUART. 5</div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="1320" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 1006 WIDTH="160"><div> SUPINE POSITION:</div> <div> a b<IMG SRC="0753b5f0.jpg" border=0 width="59" height="95" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="076486a0.jpg" border=0 width="72" height="106" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>0 to 8 weeks</U>: asymmetrical posture(a): the body axis curves, the head goes from one to the other side but cannot be maintened in the median position.</div> <div> <U>6-8 weeks</U>(b): supple fencing posture when the child wants to get one's bearings, or to build a relationship with the environment.</div> <div> <U>2-3 months</U>: increasing symmetry of the body axis, median head, stable posture, first motor expression with the upper limbs: jerky movements, in a circular form, elbows in extension and open hands.</div> <bR> <div> PRONE POSITION :</div> <div> c<IMG SRC="07e994e0.jpg" border=0 width="153" height="78" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>0-8 weeks</U>: supporting on the forearms, weight on the wrists</div> <div> d<IMG SRC="07d954e0.jpg" border=0 width="149" height="78" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>3 months</U>: increasing symmetrical support on 2 elbows (d) the head is then raised, the child gets one's bearings by free head rotation.</div> <bR> </tD> <tD VALIGN=CENTER WIDTH="222"><div> SUPINE POSITION:</div> <div> e<IMG SRC="079763b0.jpg" border=0 width="118" height="59" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>From 3 months</U>: symmetry of the body (e), median head and free rotation (without corporal imbalance), medium posture of the 4 limbs, raised in the space (about 90° flexion of the lower limbs), stability of the supine position that enables the child to build immediately and constantly a reliable relationship with the environment (postural safety).</div> <div> f<IMG SRC="07a50430.jpg" border=0 width="80" height="67" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> That is the essential condition for the appearance of the prehension about 4 months (f): on one or the other side with the correspondent hand, then, about <U>4,5 months</U> on the corporal median axis , and about <U>5 months</U>, beyond this axis to pursue an object. this pursuit will bring to turning from the supine to the prone position. NB: The manual prehension induces usually an associated feet prehension.</div> <div> At the end of the quarter 2, the knee flexion decreases.</div> <bR> <div> PRONE POSITION:</div> <div> g<IMG SRC="07c95810.jpg" border=0 width="149" height="129" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>4,5 months</U>: support on 1 elbow (g): prehension of an object forwards without creating a corporal imbalance by supporting automatically on the knee of the same side.</div> </tD> <tD VALIGN=CENTER WIDTH="192"><div> SUPINE POSITION:</div> <div> h<IMG SRC="084b6700.jpg" border=0 width="182" height="112" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>6 months</U>: turning from supine pos. to prone pos. (h)</div> <div> Bimanual coordination to handle objects, put them into the mouth, later to examine them at a distance.</div> <div> i<IMG SRC="0825d420.jpg" border=0 width="93" height="66" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> Hands - feet coordination (i), later hands - feet - mouth coordination </div> <div> J<IMG SRC="0814e3d0.jpg" border=0 width="78" height="61" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>7 months</U>: stable lateral posture, shoulder on the ground, later supporting on 1 elbow (j:<U>8 months</U>), and oblique sitting with one hand (k: <U>9 months</U>).</div> <div> k<IMG SRC="0804b450.jpg" border=0 width="75" height="69" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <div> PRONE POSITION</div> <div> l<IMG SRC="07f5e370.jpg" border=0 width="94" height="55" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>6 months</U>: supporting on 2 open hands (l);</div> <div> <U>7 months</U>: coordinated turning prone-->supine (without falling);</div> <div> <U>8-9 mois</U>: crawling like a seal (traction with the upper limbs), within a short time because this activity will soon turn into a quadrupedic crossed locomotion.</div> <bR> </tD> <tD VALIGN=CENTER WIDTH="311"><div> m<IMG SRC="086bc960.jpg" border=0 width="188" height="150" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>9-10 months</U>: coming to sitting by the previous quadrupedic position and a lateral transfer of the corporal weight. </div> <div> n<IMG SRC="0888e820.jpg" border=0 width="142" height="130" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <U>9-10 months</U>: free long sitting (with supple limbs)</div> <bR> <div> <U>9-10 months</U>: crossed quadrupedic locomotion (o) <IMG SRC="08c824c0.jpg" border=0 width="130" height="76" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">and verticalisation by pulling with the upper limbs (p)<IMG SRC="08b75a90.jpg" border=0 width="117" height="169" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> </tD> <tD VALIGN=CENTER WIDTH="405"><div> <U>12 months</U>: lateral steps with help of the upper limbs (all along the walls or furnitures), </div> <div> <U>12-14 months</U>: free standing and free walking</div> </tD> </tR> </TABLE></div> <bR> <div>  <A NAME="appeal"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Appeal</B>: </div> <div> Need, attraction to an object, a person or an activity, that urges the child to act. The visual appeal is an essential dynamic factor during the first trimester of development: to orient efficiently his head, the healthy baby uses complex postural automatisms including especially a supporting function on the upper limbs, the active stabilization and the symmetry of the corporal axis.</div> <bR> <div>  <A NAME="axecor"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>axis (corporal-)</B>:</div> <div> Longitudinal potential axis of the body (generally assimilated to the axis of the spine). During the 2 first months, the corporal axis can not be spontaneously aligned by the baby that is always asymmetrical; this asymmetry has however to be reciprocal (DB); in the opposite case, a postural anomaly can already be suspected. At the age of 3 months , the corporal axis will become automatically symmetrical thanks to a more precise coordination of muscular synergisms. </div> <bR> <div> Ã©quilib<B>balance</B>:</div> <div> Aptitude to guarantee the stability of the body in all circumstances (postural stability). Balance is impossible without a muscular action against the gravity. A posture is stable when the corporal gravity center (C.G.) projects inside the support polygon (potential surface delimited by the support points). When the C.G. is no longer vertically above this surface, the body is unstable, then the posture or the polygon have to be modified to avoid a fall. The postural stability has to be automatically insured to start any functional activity without displacement, but also during the locomotion. </div> <bR> <div>  <A NAME="ccd"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>central coordination disorder (CCD)</B>:</div> <div> Diagnosis expression designating a temporary neurological situation of the baby when the clinic examination already reveals anomalies of the postural automatic reactivity (DB), with a delay or anomalies of the spontaneous motor function, with or without associated disorder of the reflexology. This transitory situation concerns essentially the first year of life, and can evolve either to a progressive neurologic standardization, spontaneous or helped by a proprioceptive physiotherapy (light disorders) (DB), or to the progressive realization of a cerebral palsy (severe disorders). It is the right time for a precocious proprioceptive therapy (DB) because of the great cerebral malleability (DB) and the rapid organization of the central nervous system during this period.</div> <bR> <div>  <A NAME="cin"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Ã©sio<B>cinesiology</B>: </div> <div> Qualitative study of the movement and of its components. The cinesiological approach of the development, is a qualitative study of the posture, the movement, used patterns, upright mechanisms, implied muscular games. </div> <bR> <div> <B>corporal scheme</B>:</div> <div> Mental image of one's body that everyone get. The corporal scheme is gradually built thanks to the sensory, postural and motor experiences, and to the interaction with the environment. Sensory, postural or motor disorders are therefore liable to disturb the development of the corporal scheme. </div> <bR> <div>  <A NAME="cpchild1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>CP child: frequent question 1: stiff or floppy?</B>:</div> <div> Extract from an US web forum of neurology, 1998: My son is 2 years old. He has mild CP. He has mild ataxia and spastic diplegia. When he is sitting, he is stiff from his waist down and floppy from his waist up. When he is standing (he can only stand with support from us or furniture) he is just the opposite, weak in his legs and strong and stiff in his arms. Can anyone explain this? How can it switch like that? </div> <bR> <div> That's a very typical question and a sensible observation from the parents. The classic answer to this question is the fluctuation of the muscular tonus (DB), that appears in every kind of CP because of the central nervous system disorder. But some neurologists and therapists in Europe have another vision:</div> <div> 1) standing, sitting, and all the locomotor functions are based on primary, innate, global mechanisms, that improve progressively in the course of the development. Their coordination improves, so that they can no longer appear under their initial form.</div> <div> 2) This improvement of the coordination is compromised by the central lesion of the CP child; he has to find another way to assure the stability of his postures and movements. All what we can see is a combination of compensation activities. As the optimal motor pattern (DB) is not available, the CP child has to use a basic pattern in which the main components are a rest of the neonatal activity:</div> <div> - Stiff legs: when you stand up a new-born child on his legs, he gives a reflex push (called "support reaction")</div> <div> - Stiff arms: when you put a finger in the hand of a new born he grips firmly (grasping reflex) to his trunk.</div> <div> - Floppy trunk: a new born child cannot maintain his trunk aligned etc... the comparison could go on...</div> <div> That also means that an adequate physiotherapy, instead of standing or sitting exercises, has to offer to the child a chance of developing <B>a better automatical coordination</B>. That's a very<B> specific proprioceptive work</B>. To get an idea about that work, just have a look at "Vojta concept" (DB).</div> <bR> <div>  <A NAME="pointfix"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>fixed point (corporal)</B>:</div> <div> To control his posture despite the gravity, a baby has to create actively support points, or fixed points, from which he will be able to stabilize, then to erect, his body in the space. The geometrical surface connecting these fixed points is called support polygon (see on this site: development / table). The first main support points are created on the upper limbs (6 first months in the prone position ) then on the lower limbs (trimesters 3 and 4). The active creation of these support points demands a very precise muscular coordination. The main problem of children with a cerebral lesion for example, is a muscular coordination deficit compromising the creation of the fixed points. It is then unavoidable that these children try to stabilize their posture by postural compensation patterns (DB). These motor succedaneas are however very different in their organization of an optimal pattern, a lot less efficient, and make gradually perennial the stereotyped motor function that characterizes the cerebral palsy. </div> <bR> <div>  <A NAME="hyperext"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>hyper-extension</B>: frequent posture of CP children, that can be occasional or quasi -constant, characterized by rejecting the head backwards and a global stiff extension of the trunk and of the limbs. This pathological posture results from a severe disorder of <B>motor coordination</B>, it disturbs the daily life and the therapy. <B>It has been often thought, but wrongly</B>, that to reduce this attitude it is positive to place the child in flexion, or to roll shoulders forwards. This frequent error, if it is repeated in the daily life, has for consequence to favor the spine cyphosis and the progressive degradation of the upper limbs mobility, already very compromised at these children. Moreover, hyper-extension alternates often with very clear forwards bending of the trunk, because of the insufficiency of the postural control; hyper-extension is the only child's means to support the posture, it is nearly always a (<B>DB</B>) compensation mechanism, used for various purposes, to straighten the trunk as well as to show anger, for example. The only reasonable solution comprises two elements: </div> <div> -1) <B>during the therapy</B>: research techniques stimulating the active alignment of the vertebral axis with support points at the four limbs. </div> <div> 2) <B>daily life</B>: select fittings using support areas corresponding to the end of the first normal development trimester. More information about this point: </div> <bR> <div>  <A NAME="innacq"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>innate - acquired</B>: </div> <div> Every child is born with a motor, sensory, relational patrimony. The birth is especially a change of environment and physical conditions to which the baby will have to adapt this patrimony. The gravity is an obstacle to outclass but also a permanent reference whom nervous system needs to manage the motor evolution. The proprioception (DB) plays an essential role in the transformation of the innate behaviours into new behaviours including all mechanisms of the postural antigravitical control . In the course of his development, the child can only conscious discover a tiny part of these transformations. The motor development is therefore especially a constant mutation from elementary automatisms in more complex automatisms. The essential catalyst of these mutations is the relational appeal (DB) of the child towards his environment. One sees therefore that the sensory development, the mental development and the motor development are intimately linked. </div> <bR> <div>  <A NAME="interac"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>interactions in the development</B>: The separation of the different development aspects (sensory, motor, mental, ...) is artificial, it corresponds to a didactic need, and facilitates the comprehension of an evolution in which all factors are in permanent interaction. Stages of the postural and motor development are the expression of the psychological and sensory evolution, but they are simultaneously the tool and the mediator of this evolution. For example, the control of the posture contribute to a richer relationship with the environment, which necessitates a more and more precise postural and motor activity. Thus, the body is gradually used according to increasingly coordinate patterns, automatically enslaved to variable finalities according to circumstances.</div> <div> Nevertheless, it is possible to classify postural and motor strategies into three main categories responding to fundamental needs of the baby: <B>orientation, consumption, locomotion</B>. </div> <div> <B>Orientation</B> necessitates, from the first trimester, the development of the support function of the upper limbs to stabilize the spine, to raise the head in the space, and to improve thus the output of the telereceivers (eye, ear, nose). The orientation need is behind the symmetrical support on 2 elbows (3 month) or the support on hands (6 month).</div> <div> <B>Consumption</B>, necessitates rapidly the installation of the body in a stable attitude, and the liberation of the sensory organs such as mouth, or hands. The need to consume the environment contributes to the appearance of prehension, of hands-feet meeting, of sitting etc...</div> <div> <B>Locomotion</B> (DB) reveals a need to appropriate and to consume also distant objects. The perception of the distant environment, generates a frustration of the child who wants now to consume what he sees at a distance too, and takes therefore locomotive initiatives. Postural and motor strategies used for the locomotion requisition generally the upper limbs to reorganize all the corporal structure ( rolling, creeping, quadrupedic locomotion, ...).</div> <div> In this interactive context, we understand why spontaneous postures of a child can show the quality of his motor, but also sensory and mental development.</div> <bR> <div>  <A NAME="locomot"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>locomotion</B>: </div> <div> Function of the living beings by which they insure actively the displacement of their whole organism. The passage from a posture to another can be also considered as a locomotive act. The locomotion is composed of 3 indissociable elements: a) postural automatical reactivity (DB) b) raising-uprighting (DB) c) movement. Each of these components is automatically managed by the nervous system. In the course of the ontogenese (DB), the locomotion transforms into passing by transitory locomotive modes increasingly coordinated until the bipedal locomotion at the beginning of the second year. The timing of this evolution can be moderately variable from a child to another, but the director scheme and the fundamental cinesiological components of this evolution are rigorously identical for all the healthy children because they live in the same gravity conditions. All the children use particularly a crossed pattern (DB) with torsion of the corporal axis. </div> <bR> <div>  <A NAME="locoref"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>locomotion (reflex -)</B>:</div> <div> The reflex locomotion has been described by the Prof. V. Vojta (neurologist). It is a set of motor coordinated patterns (DB) , artificially activated by adequate stimulations since the birth. These provoked activities contain all mechanisms of the human locomotion and are used in a therapeutic purpose. (more information, see on this site : rehabilitation / Vojta concept). </div> <bR> <div>  <A NAME="motautcon"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>motor function: automatical or conscious</B>? </div> <div> It's often said that the acquisition of a new motor capacity necessitates first an aware apprenticeship to automate then the learnt gesture. In the course of the normal development, the motor act is effectively always released by the intention to get a particular result; the gesture is therefore finalized, but that does not mean that its realization is aware, indeed the concrete realization of the movement and the control of an attitude are entirely automatic. Need to act generates an action that begins with an improvisation on the basis of already refered and immediately available automatisms. That's why the first action is not always perfectly adapted to the situation; but in the course of this action, the nervous system is constantly informed about the progress of operations and their results by its various afferent sources (vision, and particularly the proprioception ...) and modifies instantaneously its motor production. The movement never finishes therefore exactly as it began, it becomes more precise in the course of its own realization and by the repetition. It is only a posteriori, and very partially, that we can acquire a relative conscience of the realized movement whose management has been <B>automatic from the beginning</B> to the end. </div> <bR> <div>  <A NAME="motspon"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>motor function (spontaneous)</B>: </div> <div> The spontaneous motor function of a baby during the first year expresses the quality of the development and the degree of maturation. Contrarily to some fréquent ideas, all the healthy children use the same postural fundamental mechanisms through the different stages of the ontogenese; they have indeed a common problem to solve: to control automatically their corporal posture despite the gravity. In order to attain this, they have the same anatomical means (the musculature), the same system of management (the nervous system) and the same phylogenetical potential (DB). The optimal solutions to this problem will be therefore the same for everyone and it is only the possible presence of a pathological process, depriving the child of a part of its means, that will constrain him to alter his postural mechanisms and to use less effective motor strategies. The alteration of postural mechanisms used by the children varies according to the nature of pathologies, that's why the attentive and codified examination of the spontaneous motor function provides information about the quality of the motor, but also sensory and mental development. </div> <bR> <div>  <A NAME="neurocia"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>neurocinesiology (children)</B>: observation method of spontaneous and provoked postures and movements of a child (in defined conditions), in order to deduce some information about his neurological functional situation and about the quality of his development </div> <bR> <div>  <A NAME="ontog"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>ontogenese</B>:</div> <div> Development of the individual since the fertilized ovule until the adult state </div> <bR> <div>  <A NAME="forcing"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>pathing</B>:</div> <div> fundamental technique of proprioceptive stimulation used during the Vojta therapy. "pathing" consists of stimulating the global muscular contraction from pressures applied on reflex zones. As soon as the movement appears, the therapist opposes a resistance that allows to prolong artificially its duration, to correct its direction, to improve the dosage of the muscular synergies by recruitment of supplementary neuronal connections that induce a better motor coordination. pathing obtains for the patient a new sensory image of its own body. </div> <bR> <div>  <A NAME="sch_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Ã¨mot<B>pattern (motor-)</B>:</div> <div> Framework, global architecture of the posture and of the movement. An economic and precise organization of the posture enables the optimal execution of the finalized motor act. This functional totality never appears at random: each functional motor pattern includes precise raising mechanisms and a coordinated postural reactivity that concern the whole body, even when the wished action concerns apparently only one corporal region (for example: writing).</div> <div> The different forms of human locomotion are based on a crossed pattern, including a twisting effect of the corporal axis. </div> <bR> <div>  <A NAME="phylog"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>phylogenese</B>:</div> <div> Evolution of the animal and vegetable species in the course of the generations </div> <bR> <div>  <A NAME="plastigb"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>plasticity - malleability</B>:The organization of the human nervous system is not definitive at the birth. The neuronal network can develop multiple different types of connections, it can also lose some of them. This structural plasticity is influenceable by adequate stimulations, that are systematically to research in precocious rehabilitation programs.</div> <bR> <div>  <A NAME="r"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Ã©acpos<B>postural reactivity</B>:</div> <div> Automatic function of the nervous system that consists of constantly managing and adapting the global corporal posture from the proprioceptiv data. The automatic postural reactivity is a basic function included in every motor finalized activity . This function evolves in the course of the development, it can be tested from the birth. Precocious disorders of the postural automatic reactivity may announce the ulterior appearance of a cerebral palsy. </div> <bR> <div>  <A NAME="posture"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>posture</B>:</div> <div> Actively obtained and maintained attitude . The optimal postural control necessitates a precise automatic coordination of muscular games by the nervous system. The global control of the corporal posture is preliminary to the realization of every finalized movement: the gesture emerges from the posture. The posture has therefore to be constantly and automatically actualized during the locomotor or motor act. This automatical and permanent actualization is managed at different levels of the nervous system, that is the postural reactivity (DB). </div> <bR> <div>  <A NAME="refprim"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>primary reflexes</B>:</div> <div> Characteristic reflex group of the neonatal and postnative period. Most of them disappear gradually in the course the first months; in fact they are integrated to a superior coordination , as it may be proved by their possible resurgence in some later pathological situations, or their persistence in a few forms of cerebral palsy. They show a neonatal nervous maturity level. The configuration of these reflexes, their period of validity is precisely defined, they are therefore a reliable element of the precocious development evaluation . </div> <bR> <div>  <A NAME="proprigb"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>proprioception</B>:</div> <div> Sensitivity of bones, muscles, tendons and articulations, informing on the static, the balance function, the displacements of the body in the space, etc...</div> <bR> <div>  <A NAME="redressgb"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>raising - uprighting</B>:</div> <div> Capacity of the child to control automatically the effect of the gravity on his body to align the corporal axis, to build a symmetrical posture, and to erect gradually the body in the space. Raising (uprighting) automatisms develop from innate primary elements, perfect in the course of the ontogenese and participate in the locomotion. Their evolution is compromised in case of disorder of the postural reactivity (see this word). </div> <bR> <div>  <A NAME="r_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Ã©cipro<B>reciprocal function (postural - - )</B>:</div> <div> All forms of human locomotion (creeping, quadrupedic, walking) are constituted of an operational cycle, whose successive phases repeat alternately from one side of the body to the other side in the opposite direction. Thus the final posture of each cycle is the initial posture of the following cycle. In a normal development, this reciprocity has to appear very precociously. For example, during the first months, when the posture of the child is still asymmetrical, this postural global asymmetry has already to be reciprocal, it means that it has to invert (like in a mirror) when the child turns his head. An monolateral asymmetry (head always turned to the same side with the corresponding global posture) is always suspect . </div> <bR> <div>  <A NAME="rotat"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>rotation</B>:</div> <div> a) Most of the trunk muscles and of the limbs roots muscles have an oblique situation compared with the corporal axis. Every motor activity uses long muscular chains whose general disposition is therefore oblique too . When these chains act in synergism they induce inevitably a twisting effect on the corporal axis, that means a vertebral rotation. </div> <div> b) Every coordinate movement begins with the stabilization of the vertebral axis from peripheral fixed points (DB), to guarantee a stable posture allowing the precise movement orientation.</div> <div> c) The different forms of human locomotion are based on a crossed pattern, including a twisting effect of the corporal axis (see: locomotion).</div> <div> These 3 observations show that the fine control of the vertebral rotation is a fundamental element of the postural and motor normal evolution. Every rehabilitation program must necessarily take this fact into account. </div> <bR> <div>  <A NAME="stas"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Ã©lec<B>selective stabilization</B>:</div> <div> The plasticity (see this word) of the central nervous system is very important during the first months of life. Potentially available neurological itineraries for the transmission of impulse are, in this period, overabundant. A selection is gradually done , with degeneration of the few solicited connections, while the most used connections get their maturity, and take on the responsibility of various functions: that is the selective stabilization. This process offers a functional compensation appropriateness in case of neurological lesion; it decreases at the end of the first year, and that corresponds to a diminution of the central malleability. Every lesion of the central nervous system has therefore to be detected very precociously and followed by a neurological appropriate rehabilitation (proprioceptive and glogal) to preserve the best chances of satisfying functional evolution.</div> <bR> <div>  <A NAME="substitu"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>substitute (or deviant) pattern</B>:</div> <div> In case of severe CC D (DB), the child is unable to manage automatically and efficiently his postures and his movements in the daily life; he musts therefore resort to the immediately available primary automatisms. The CCD disrupts and brakes the transformation of these automatisms. They become therefore gradually, with the repetition, the framework of a limited range of stereotyped motor strategies. These substitute or deviant patterns are the only way for the child to satisfy the daily life needs; they slow down the development of the motor autonomy.</div> <div>  <A NAME="polygsus"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>support polygone</B>:</div> <bR> <bR> <div>  <A NAME="polygsus_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Potential polygon delimited by the corporal fixed points (see this word) . This polygon is naturally invisible, nevertheless it is a fundamental cinesiological datum during the examination of a child, to better understand his postural organization and possibly to guide a therapy. </div> <bR> <div>  <A NAME="sinergb"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>synergy (muscular - )</B>:</div> <div> Automatically coordinated action of various muscular groups to get a functional result. </div> <bR> <div>  <A NAME="therapgb"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>therapy (precocious -)</B>:</div> <div> The precocious screening of severe CCD (DB), with clear neurological anomalies, allows the rapid installation of a precocious proprioceptive physiotherapy. Ideally, it would have always to begin during the first trimester of life to make the best use of the nervous system plasticity (DB). When the therapy begins in the course of the third or the fourth trimester, the intelligent child, uses already regularly in the daily life substitute or deviant patterns (DB), to establish a motor relationship with the environment. The repetition of these abnormal motor activities contributes to integrate them definitively and concretizes the installation of the CP ( cerebral palsy). A very precocious global physical therapy prevents this phenomenon and preserves some odds of a more physiological postural and motor evolution. </div> <bR> <div>  <A NAME="tonus"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>tonus (muscular - )</B>:</div> <div> Permanent and involuntary tension state of the muscular tissue, depending from the peripheral and central nervous system. The appreciation of the muscular tonus is based on various small means (often varying from one examiner to the other) rather than on a clearly codified and unanimously recognized methodology . There is no measure unit of the muscular tonus. The tonus varies at one time according to the state of the person, according to her activity; in some pathologies the muscular tonus may be, at the same time, very different from a corporal region to the other. In these conditions the muscular tonus can be an useful element of observation to characterize some pathological situations, but constitutes in no case a decisive criterion in the therapeutic argument choice composing a motor rehabilitation program. </div> <div>  <A NAME="voj1conc"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Vojta concept</B>:</div> <bR> <bR> <div>  <A NAME="vthfaqgb"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Vojta therapy: parents question</B>:</div> <div> <B>Question 1</B>: Our son was born prematurely, suffered IVH and PVL, with resultant hemiplegia. He is now 6 months corrected age and we are beginning Vojta Therapy. Today was our son's second therapy session. So far we are working with only a single exercise, to strengthen his diaphragm, I believe. The exercise consists of applying pressure to his rib cage on one side below the nipple and above the last rib for a period of 10 seconds or more as he allows. He must face towards the side being manipulated or straight ahead. We repeat this exercise four times on each side per session, with three sessions each day. Am I correct that this is to strengthen his diaphragm?</div> <bR> <div> <B>Answer 1</B>: The problem of your child is not "strength" but coordination of the pattern and therefore of the movement.</div> <div> a) we use a stimulation on the thorax reflex zone (pression), we get a contraction of the diaphragm; thats naturally very useful for breathing!... </div> <div> b) but it's also the start point of a larger global reaction of many muscles (thorax, shoulder blade, spine, arms and legs). we exactly know what should be this reaction in an optimal development at every age and try to develop it artificially.</div> <div> To see the <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>good reaction </U></FONT>click here and have a look at the picture "e" (3 months). A child able to create this posture is already aligned, symmetric, stable, and can turn his head in both directions without loosing his balance...! Do you imagine what it means for an hemiparetic baby to live for the first time a symmetric, aligned, balanced posture...? it's a greatful experience! That's a 100% automatic experience; he will have only a very partial consciousness of that much later. Tnhat's a so fabulous experience that he loses its usual corporal points of reference, and that's why he cries! (it's not painful). In the normal development, this stage (3 months) is the body preparation to the "hand taking"; that's why a child will begin to take an object with his hand at 4 months...</div> <bR> <div> <B>Question 2</B>: Is this pressure meant to compress the lungs thereby making him work harder to breath?</div> <bR> <div> <B>Answer 2</B>: Not only "harder" but above all "different" and "better". Better breathing means with a specific activity of the abdominal muscles. 80% of these muscles are oblique and very important to turn from the back to the prone position (on his stomach!). Do you understand how useful it could be when you told me recently " he rolls on to both sides by himself but never over on to his stomach without assistance"...? </div> <bR> <div> <B>Question 3</B>: What the heck is stimulated by the pressure? Is it particular nerves located at the point where the pressure is applied? A pattern of nerves as the pressure is diffused over the ribcage? The muscles themselves, by directly stimulating a contraction? The result of pressure on the internal organs? Proprioceptive sensitivities that help him locate his muscles? What is the physiological mechanism underlying the effectiveness of this first exercise? And why this particular spot on the thorax and not somewhere else? I'll certainly keep doing what I've been doing, but I'd sure like to know, not so much why for its own sake, but why so that we can be as effective as possible. </div> <bR> <div> <B>Answer 3</B>: certainly not one particular nerve, but all what you say in your question together...and more... Contraction of the diaphragm and abdominal muscles, pressure on the lung and pleura, pressure on the mediastinus because of the abdominal contraction, activity of the intercostal musculature, stimulation on the rib periost, pressure and movement in the rib - spine joints, etc... many different afferent ways are activated simultaneously. Why on that point?... because anywhere else we cannot get the same effect! Don't forget it was an empiric discovery. We don't understand completely why, but we observe exactly what happens and how the answer progresses. Another reason is: each "zone" is able to provoke a complete pattern of reflex locomotion by a new</div> <bR> <bR> <div> <B><U>The Vojta "method"</U></B></div> <div> is for the physician a precious clinic tool for the evaluation of the child development from birth, and a <B>reliable element of diagnosis</B>; it is for the physiotherapist an efficient <B>global therapy</B> which can be used from the first days of life, in a preventive or curative intention.</div> <bR> <div> The treatment based on the reflex locomotion contributes to: </div> <div> * <B>Modify the reflex activity</B> of the young child and to orient the <B>neuromotor development in a more physiological direction</B>, by the induction of a different central neurological activity that supplies to the patient a new corporal perception. The muscular "proprioception" plays here a very important part.</div> <bR> <div> * Modify the <B>spinal automatisms</B> in lesions of the spinal cord .</div> <bR> <div> * Control the <B>breathing</B> in order to increase the vital capacity.</div> <bR> <div> * Control the <B>neurovegetative reactions </B>, and promote an harmonious growth of the locomotor anatomical system . </div> <bR> <div> * Prevent the <B>orthopaedic degradation</B>, frequent in severe pathological situations.</div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="570" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FF00FF HEIGHT= 44 ><NOBR><div> <B>Comparison of reflex creeping sequences</B></div> <div> <B>with spontaneous motor sequences of the ontogenese</B></div> </NOBR></tD> </tR> </TABLE></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="732" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#00FF00 HEIGHT= 57 ><NOBR><div> <B>Reflex creeping</B></div> <div> <B>(artficially provoked activity)</B></div> <div> <B>Activity</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#00FF00><NOBR><div> <B>Appearance age</B></div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#FFFF00><NOBR><div> <B>Ontogenese</B></div> <div> <B>(finalized, spontaneous activity) </B></div> <div> <B>Appearance age</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FF00 HEIGHT= 75 WIDTH="291"><div> lateral step of the upper limb in prone position</div> <bR> <div> elbow support</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FF00 WIDTH="158"><div> from the birth </div> <div> (nape arm) </div> <div> (face arm)</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFF00 WIDTH="263"><div> 3 months</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FF00 HEIGHT= 38 WIDTH="291"><div> Free coordinated head rotation with symmetric vertebral axis</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FF00 WIDTH="158"><div> from the birth</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFF00 WIDTH="263"><div> 3 months</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FF00 HEIGHT= 38 WIDTH="291"><div> Lateral movements of the eyes, independent of the head posture</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FF00 WIDTH="158"><div> from the birth</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFF00 WIDTH="263"><div> end of the 1 quarter </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FF00 HEIGHT= 38 ><NOBR><div> One elbow support</div> <div> (support stabilizing synergisms)</div> </NOBR></tD> <tD VALIGN=CENTER BGCOLOR=#00FF00 WIDTH="158"><div> from the birth</div> <div> (face arm)</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFF00 WIDTH="263"><div> middle of the 2 quarter </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FF00 HEIGHT= 57 WIDTH="291"><div> Total opening of the hand, with radial bending of the wrist , abduction of the metacarpus</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FF00 WIDTH="158"><div> from the birth</div> <div> (nape hand)</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFF00 WIDTH="263"><div> end of the 2 quarter</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FF00 HEIGHT= 38 WIDTH="291"><div> Coordinate differentiation of the shoulder and pelvic belts</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FF00 WIDTH="158"><div> from the birth</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFF00><NOBR><div> 6 months, rolling from dorsal to ventral</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FF00 HEIGHT= 57 WIDTH="291"><div> Activ creation of the knee support with loading</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FF00 WIDTH="158"><div> from the birth nape lower limb, variant of the ref. creeping)</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFF00 WIDTH="263"><div> quarter 3</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#00FF00 HEIGHT= 57 WIDTH="291"><div> Coordinate push with the lower limb and heel support, foot in the 90° position, support on the external foot edge.</div> </tD> <tD VALIGN=CENTER BGCOLOR=#00FF00 WIDTH="158"><div> from the birth (nape lower limb)</div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFF00 WIDTH="263"><div> 14 -15 months</div> </tD> </tR> </TABLE></div> <bR> <bR> <bR> <div> <B><U>INDICATIONS OF THE V. VOJTA TECHNIQUE</U></B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe and medium central coordination disorders</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Light but asymmetrical central coordination disorders</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cerebral palsy</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Muscular and neurogen torticolis </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Peripheral Paralyses (child and adult) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Spina bifida</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Congenital myopathies - congenital deformities (athrogryposis, club foot etc...) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Morbus-Down syndrome and other syndromes - motor delays </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Various postural disorders (scoliosis, cyphosis)</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hip dysplasies </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Adult hemiplegy (unexhaustive list)...</B></div> <bR> <bR> <bR> <div> <B><U>Growth and Development of the Infant</U></B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2 critical time periods of weight and linear growth are in infancy and adolescence.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Best indication for overall good health in infancy is a steadily increasing height, weight, head and chest circumference. These are plotted on a growth chart and monitored from birth to 2 years of age. It is used to compare with other children and is individualized.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">How do they know when there is a problem? When the weight falls behind height by </B><B>2</B><B> standard deviations and when the pattern of weight and height percentiles indicate a decrease.</B></div> <bR> <bR> <div> <B>Physical Growth</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Height:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Average birth length is 20 inches.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Height increases 50% by 1st year.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gain about 1 inch/month for 1st 6 months.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1/2 inch/month for next 6 months.</B></div> <bR> <bR> <bR> <div> <B>Weight:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">By 5-6 months should be doubled.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">By 1 year, should be tripled.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Head Circumference:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">At birth, greater than chest circumference.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Average is 13 3/4 inches.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">By end of 1st year head and chest circumference is equal. (18").</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">By end of 2 years, chest becomes larger.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In daily assessment do head circumference.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In 1st 6 months, increases about 1/2 inch/month.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Last 6 months, increases about 1/4 inch/month.</B></div> <bR> <bR> <div> <B>Fontanelles:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Posterior closes at 2-3 months.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anterior closes at 12-18 months.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vital signs:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pulse at birth = 120-160.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pulse by end of 1st year = 100-120.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Resps = 20-50, average is 30.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Abdominal respirations = diaphragmatic.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">BP average is 85/60 for 1st year.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Temp is usually axiallary except for first one.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Axillary is 1 degree less than oral.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rectal is 1 degree higher than oral.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When elevated, take more frequently.</B></div> <bR> <bR> <bR> <div> <B>Teeth: dentition.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">At 3 months, begin to drool (more saliva).</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Haven’t learned to coordinate swallowing.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Teeth begin to erupt at 6 months.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">First set is called deciduous or primary teeth.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">How teeth come in may affect speech.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Full set of primary is complete by 30 months or 2 1/2y.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Have about 6 by end of 1st year.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Red, swollen, and painful gums accompanies teething.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fever and diarrhea is </B><B>not </B><B>typical with teething.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If they do have diarrhea or a fever, it is due to low maternal antibodies; therefore resistance to infection is lower.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Topical anesthetic can be used.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cool teething rings numb sore areas.</B></div> <bR> <bR> <bR> <div> <B>Developmental Milestones</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These norms are valuable for comparing and predicting normal development. They are still going to have an individual pattern.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gross Motor:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Posture</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Head control. From 1 to 3 months can turn side to side and can follow an object in front of their face. By 4 months if lying on stomach can lift head up and chest comes up 90 degrees. By 4 to 6 months, head control is well established.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rolling over. From 3 to 6 months, baby can roll from stomach to back and vice versa. Don’t leave unattended. By 7 months, have </B><B>parachute</B><B> reflex = trying to hold it self up, arms and legs and head will go out, protective measure.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sitting. By 6 months can sit without support for a short time. By 8 months can sit well alone. By 10 months can go from prone to a sitting position.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Crawling. By 9 months because flexor muscles are stronger. Can pull themselves up using sides of furniture.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Walking. By 11 to 12 months can walk holding onto furniture. By 13 months can walk well by themselves.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fine Motor:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ability to use hands and fingers in </B><B>prehension</B><B> = ability to grasp an object. Develop from proximodistal.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000008000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Newborn</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> usually keeps their hands in a grasp reflex.</B></FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3 months normally hold hands open most of the time.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3 months will swipe at an object but cannot grasp it.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">5 months voluntarily grasp an object.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">7 months banging things together.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">7 months palmer grasp.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">8 months prehension occurs.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">8-9 months crude pincer grasp. Forefinger in opposition to thumb.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">10-11 months neat pincer grasp. This is why at 10 months can find minute things and put in their mouth. Excellent time for finger foods. Popcorn is a no-no.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">12 months can build a 2-block tower.</B></div> <bR> <bR> <div> <B>Sensory Development</B><B>:</B></div> <div> <B>Touch:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Form of stimulation.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">How environment is learned.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Important to provide active and passive touch.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Active = toys, rattles, textures.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Passive = caregivers touch.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Taste:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prefers sweet over sour.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Smell:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Learn to smell breast milk and associate it with mom.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Respond to irritating odors.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hearing:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Can distinguish mom’s voice from stranger’s.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">8 months, will attempt to imitate sounds.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">10 months, able to recognize name and turns head when hears it.</B></div> <bR> <bR> <div> <B>Sight:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Eye contact is first social contact.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Can see and discriminate patterns.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1 month can see 18 inches away.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1 to 3 months likes the human face.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3 to 6 months, smiles at familiar faces, but not a strangers.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Eye Color:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Not established until 6 to 12 months.</B></div> <bR> <bR> <div> <B>Psychosocial Development</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trust vs. Mistrust.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Quality of caregiver and child’s relationship and consistency of care is important.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Attentive and timely care will teach them to trust their environment.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When a child’s needs are met consistently, they develop faith and optimism.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">An infant needs routine and sameness of experience. Needs a workable schedule.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Needs same nurse.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Read same stories over and over again because they learn to trust the pattern and outcome.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cognitive Development</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sensorimotor phase: ages 0 to 2 years.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reflex to imitative to repetitive behavior.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1 to 4 months, can’t differentiate, trial and error behavior.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4 to 8 months, attention shifts to objects.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3 crucial events from birth to 12 months:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Learns to separate themselves from other objects.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Learning object permanence.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Begins to use symbols or mental representations. The recognition of these symbols is the beginning of the understanding of time and space.</B></div> <bR> <bR> <div> <B>Play</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Solitary play. No interaction with others.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Will play with mom and dad or someone they know.</B></div> <bR> <bR> <div> <B>Stimulation and Play:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1 to 3 months:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Likes voices and music for auditory stimulation. Crib mobiles and looking face-to-face stimulates visually. Tactile stimulation is achieved by stuffed animals and other toys with texture. Other things they like are to be carried and rocked, rattles, mirrors, and moving toys. Always remember toy safety.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4 to 6 months:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">More aware of self and environment. They laugh and "talk" a lot. Likes blocks, crib gym, toys that imitate animal sounds and all toys that make noise.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">7 to 9 months:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Begin stranger anxiety, a.k.a. separation anxiety </B><B>(6-8)</B><B>. Do not confront abruptly. Likes peek-a-boo, patty cake and toys that disappear and re-appear.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">10 to 12 months:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Learning to be more independent. Likes toys they can put one inside the other, toys that can be pushed, containers with removable lids and large puzzles.</B></div> <bR> <bR> <div> <B>Nutrition</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1st 6 months diet is solely milk.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If breast feeding, needs only a supplement of fluoride (only if not on city water) and at 4 months, will need some iron because fetal stores of iron are depleted.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If baby cries, this does not mean it is hungry, unless it is losing weight.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Formula fed baby should be on formula for 1 year.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When put on cow’s milk, use whole milk only. Infant needs the essential fatty acids necessary for growth of nervous system.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Obesity is a problem. They need to have water also.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Advance - formula with 20% fewer calories.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Also if gaining, can dilute formula.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Substitute water for formula for a few feedings.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Give nipple with a smaller hole.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Should not be on a diet, just slow weight gain down.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Weaning</B><B>: substitute cup for bottle or breast. Should not do it cold turkey. Will show readiness at 5 to 6 months. 8 or 9 months, want to drink out of a cup because everyone else is. At 1 year, can hold and drink with assistance.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nursing bottle syndrome: when put baby to bed with bottle of milk causes dental caries.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Introducing food too early could expose them to allergies. Stomach cannot digest before a certain age.</B></div> <bR> <bR> <div> <B>Foods to Introduce</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Cereal. Fortified with iron. May be physiologically anemic. 1 to 2 teaspoons mixed with breast milk, formula or water. If too thick may cause colic. Keep on cereal up to 18 months because of iron content. Start with rice cereal because it has less allergens.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Vegetables or fruit. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fruit juices may need to be diluted.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Should have vitamin C to help with the absorption of iron. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Leave on one for four days so you know if it causes an allergy. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Should start with vegetables first. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Should puree food. At 9 months can start with junior food with more consistency. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Can feed table food, but it may have too much salt and seasonings. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Common food allergy is protein in egg whites. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Teach families that children will be messy.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sleep/Rest Needs</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sleeps 20-22 hours of the day.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Later will take 2 naps/day.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Begin a bedtime ritual.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Establish that crib is to sleep not to play.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When wake up in the night, check on them, but don’t take out.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rely on external constraints to learn behavior - use no-no sternly.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Corporal punishment does not work at this age.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Discipline needs to be appropriate.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Immunization Schedule</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Page 195. Must know.</B></div> <bR> <div> <B>Contraindications:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A. </B><B>Severe febrile illness </B><B>other than common cold.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">B. </B><B>Immunocompromised</B><B> infant or family member.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Can be deadly to either because of live virus.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Malignancy, chemo, radiation, steroids.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">C. </B><B>Severe sensitivity to eggs.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">D. </B><B>Gastroenteritis</B><B> - no OPV because polio virus must be colonized in the intestines to produce an immune response.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">E. </B><B>Blood transfusion or gamma globulin in previous 2 months</B><B>. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Will not get MMR because it is passive immunity and they will be getting someone else’s blood. Will need to wait 6 weeks.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Care Safety</B><B>:</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rear facing, in middle of back seat.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">7-9 months or 17-20 pounds, can turn around.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4 feet, 5 years, 40 pounds can be in just seat belt.</B></div> <bR> <bR> <bR> <div> <B><U>Growth and Development of the Toddler</U></B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ages 1 to 3.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Period of intense exploration of the environment.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wants to know how things work and tries to control others.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Short legs and a pot belly (lack of muscle tone).</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Legs are bowed because they must support trunk.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Growth slows down.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Will have growth spurts.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Growth chart will be in a step-like fashion.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Will go through periods of eating a lot to not eating much at all.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Average weight gain is 5-10 pounds/year.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">At 2 ½ years, should have quadrupled birth weight.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Height gain of 3"/year. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">At end of 3</B><B>rd</B><B> year, most of height is in legs.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">By 2, chest circumference is larger than head.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chest gets wider transversely.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Transverse diameter will exceed a/p diameter.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vitals: pulse = 80-120, resps = 20-40.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Toddler is usually farsighted, clearest is 6 feet.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Books should have large pictures.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hearing is acute and will use all senses to explore environment.</div> <bR> <bR> <div> <U>Nutrition:</U></div> <div> Between ages 1-3, eating problems appear for a number of reasons.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Growth rate has slowed, want and need less food than before which is normal. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Independence and autonomy, will ask for something to eat. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Appetite varies and will often want one kind = <B>food jags.</B></div> <div> How to minimize these problems: Nutritious meals should be planned.</div> <div> Will eat what they need.</div> <div> Want the same place at the table with same plate and cup.</div> <div> Ignore dawdling, unless it gets unreasonable.</div> <div> Have a calm down period before meal time.</div> <div> Expect them to be messy.</div> <div> This gradually diminishes as child gains skills.</div> <div> 15 months:</div> <div> Can sit thru meals.</div> <div> Prefers finger feeding.</div> <div> Prefers to self feed.</div> <div> Tries to use a spoon, but spills it.</div> <div> Grasps cup with thumb and forefinger.</div> <div> Tilts cup instead of head.</div> <div> 18 months:</div> <div> Appetite decreases.</div> <div> Improved control of spoon.</div> <div> Puts spilled food back on spoon.</div> <div> Holds cup with both hands, spills less often.</div> <div> Throw cup when finished.</div> <div> 24 months:</div> <div> Appetite fair to moderate.</div> <div> Clearly defined likes, dislikes and food jags.</div> <div> Grasps spoon between thumb and forefinger.</div> <div> Accepts no help.</div> <div> 30 months:</div> <div> Refusals and preferences are less evident.</div> <div> Some hold spoon and cup like adult.</div> <div> Tilts head to drink from cup.</div> <div> <U>Temper Tantrums:</U></div> <div> Realized to control others by using the word "no".</div> <div> Thru their behavior, they can control you.</div> <div> They don’t have the language skills to communicate their frustrations.</div> <div> Can’t comment on behavior, but praise when they gain control.</div> <div> Give 2 acceptable choices.</div> <div> Reasoning, scolding or punishing during a tantrum is useless.</div> <div> <U>Bowel and Bladder Training:</U></div> <div> Won’t be ready until they have sphincter control at 18 – 24 months.</div> <div> By the time they are walking, will have sphincter control.</div> <div> First control is bowel.</div> <div> Note when normal BM’s are so you can know when to put them on the pot.</div> <div> Between 2-3 control is bladder.</div> <div> May not have complete control of bladder until 3-5.</div> <div> Get potty chair to start.</div> <div> Put them on it in front of the TV to get used to it, then put it in the bathroom.</div> <div> For bladder, teach boys to aim at something in the toilet.</div> <div> <U>Piaget’s Cognitive Development:</U></div> <div> Egocentric – everything is "mine".</div> <div> Pre-operations thought.</div> <div> Imitators.</div> <div> Symbolic play – can actually participate in something even though it’s not real.</div> <div> No concept of quantity.</div> <div> Can often regress.</div> <div> Terrible two’s.</div> <div> <U>Language Development:</U></div> <div> First words said at this age.</div> <div> Helps autonomy.</div> <div> Sense of power by saying "no" and "mine".</div> <div> 300 word vocabulary.</div> <div> One or two word sentences.</div> <div> ID’s body parts and what they do.</div> <div> By 3 can count to 10.</div> <div> They take language literally.</div> <div> Feelings get hurt easily.</div> <div> Find intrusive experiences very frightening.</div> <div> Looking in ears and mouths should be done last.</div> <div> Mimics our speech at this time.</div> <div> <U>Immunizations:</U></div> <div> Read chart.</div> <div> Know MMR is usually at 15 months.</div> <div> <U>Play: </U></div> <div> Moves from solitary to parallel play.</div> <div> Will play alongside, but not with another child.</div> <div> Imitates people around them.</div> <div> Gross motor skills: push-pull, large books and balls.</div> <div> Fine motor skills: large crayons and wood puzzles.</div> <div> Check toys for safety.</div> <div> Enjoys to play like cooking.</div> <div> <U>Discipline:</U></div> <div> Discipline à to train to produce a particular behavior pattern.</div> <div> Punishment à penalizing for a wrong doing.</div> <div> 3 types of discipline:</div> <div> Consistency and timingà </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">adults should all operate by same rules </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">use messages that do not label the child as bad but label the act as unaccpetable</div> <div> Time out à </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">be alone but observed and without any distractions </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1 minute/year of age is adequate </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">one warning beforehand </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">praise children for good behavior and when possible, ignore negative </div> <div> Extinction à </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ignore as long as behavior is not harmful </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">act as though you don’t hear the child</div> <div> Spanking usually does not work well because child is taught hitting is acceptable and frequently becomes immune to it.</div> <div> <U>Accidents:</U></div> <div> Leading cause of death in ages 1-4.</div> <div> Accidents include MVA, drowning, burns, poisoning.</div> <div> Poisoning is most common accident in ages 1-4.</div> <bR> <bR> <div> <B><U>Growth and Development of Preschooler</U></B></div> <div> Ages 3-6.</div> <div> 3 likes to please = pleasing threes.</div> <div> 4 = frustrating fours.</div> <div> 5 = fascinating fives.</div> <div> 3:</div> <div> Potbelly begins to go away.</div> <div> Growth occurs in legs and feet.</div> <div> Looks long and slender.</div> <div> Agile and graceful.</div> <div> Good posture.</div> <div> Gain 3-5 pounds/year.</div> <div> Grow 2 ½" in height/year.</div> <div> Now have all baby teeth.</div> <div> When around 6, start to lose teeth.</div> <div> <U>Ericson’s Psychosocial:</U></div> <div> Initiative vs. Guilt.</div> <div> Play, work and live to the fullest.</div> <div> Period of energetic learning.</div> <div> Sense of accomplishment and satisfaction.</div> <div> Encourage to be creative.</div> <div> Give opportunities to explore different people and things.</div> <div> Made to feel guilty when they overstep what they are able to do.</div> <div> Begins to develop a conscience.</div> <div> Begin to like parent of opposite sex.</div> <div> Oedipus complex = boy likes mom.</div> <div> Electra complex = girl likes father.</div> <div> These are competition with same sex parent.</div> <div> This helps establish sexual identity.</div> <div> Love/hate relationship happen also.</div> <div> Often they have a wish for the same sex parent to leave or be dead.</div> <div> Should this actually happen by accident, the child believes he caused it.</div> <div> Difficult time distinguishing real from fantasy. </div> <div> They believe rules are fixed and they are absolute.</div> <div> They believe rules are passed down by their all knowing parents – omnipetent.</div> <div> <U>Cognition:</U></div> <div> Preoperational thought.</div> <div> Will begin to share.</div> <div> <U>Play:</U></div> <div> May have imaginary playmate.</div> <div> Do not substitute punishment onto the playmate.</div> <div> Usually occurs in children with no siblings.</div> <div> Be sure to document on chart.</div> <div> Likes to play dress up.</div> <div> Like to do things they know about such as, mom and dad, policeman, teachers and doctors.</div> <div> Still thinks literally.</div> <div> Play is associative play.</div> <div> <U>Language:</U></div> <div> Goes from 1000 words to 3000 words.</div> <div> Telegraphic speech à 3 to 4 word sentences will only include the most important words.</div> <div> Can follow simple directions.</div> <div> <U>Concerns:</U></div> <div> Stuttering à ask them to slow down and they will eventually grow out of it.</div> <div> Masturbation à curious about their bodies. Feels good. Teach that it is not acceptable in public. Normal for children to masturbate.</div> <div> <U>Other Facts:</U></div> <div> Will need a booster prior to starting school.</div> <div> Achieve full bowel and bladder control by this time.</div> <div> A common fear is of the dark.</div> <div> We need to acknowledge the fear.</div> <div> Should visit daycares periodically.</div> <div> Can give simple directions and they will follow them.</div> <bR> <div> <B><U>Care of the </U></B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B><U>Newborn</U></B></FONT></div> <div> Transition period à 6-8 hours after being <FONT SIZE="3" COLOR="#800000" FACE="Arial" >born</FONT>.</div> <div> All systems have different requirements.</div> <div> First: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Know about delivery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Know meds mom had. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gestational age. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Apgar scores.</div> <div> Order in which assessment is done:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">general appearance </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vitals every 30 minutes x 2 hours (do when quiet) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">head-to-toe</div> <div> <U>Respiratory.</U></div> <div> Chemical à when umbilical cord is clamped, baby depends on own chemistry. Becomes acidotic, pH goes down, and acidosis stimulates respirations. </div> <div> Sensory. </div> <div> Thermal à going from warm to cool, temperature decreases, brain responds to increased temperature. Normal axillary temp is 97.5-99.5. A rectal temp is always done first to check anus patency. </div> <div> <B>Mechanical</B> à lungs are squeezed when they come thru the birth canal to get the fluid out. The alveoli open up and chemoreceptors cause baby to take a breath. If C-section, this does not happen and you must do chest percussion.</div> <div> May have tachypnea = fast resps. Should go away after a couple of hours. May have apnea, greater than 15-20 should be reported.</div> <div> S&S of Respiratory problems:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">nasal flaring </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">grunting on expiration (inadequate lung recoil) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">retractions in clavicle </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">sternal (costal) retractions - between ribs </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">page 361</div> <div> Auscultate breath sounds. If you hear rales, sometimes right after birth, baby may still have amniotic fluid. If not symptomatic then not a problem.</div> <div> <U>Cardiovascular.</U></div> <div> Fetal circulation - page 294.</div> <div> When cord is clamped, mom no longer supplies oxygen. As baby takes it in, lungs fill and pulmonary artery pressure decreases then the lungs expand and oxygen goes to the baby.</div> <div> Blood volume of left side of heart is what causes foremen ovale to close. Ductus arteriosis also closes at 15-24 hours after birth.</div> <div> Ductus venosis stops functioning when umbilical cord is clamped, then baby’s liver starts to function. Will close completely in 2 weeks.</div> <div> Check heart rate. Should be 120-160. Count for 1 full minute. When crying, it can go up. When sleeping, it should go down. It should never go up when sleeping.</div> <div> Check BP in all 4 extremities. Will be around 70/40. Discrepancy may indicate cardiac anomalies.</div> <div> <U>Nervous system</U>.</div> <div> Most neurons have been completely formed. Should get a strong cry.</div> <div> Muscle tone should be good.</div> <div> Growth is from head-to-toe.</div> <div> <U>GI system</U>.</div> <div> Stomach will only hold 40-60cc (1-1 ½ oz).</div> <div> Cannot digest fat yet completely.</div> <div> Gastric emptying is 2-4 hours after they eat.</div> <div> Cardiac sphincter is immature. (spits up).</div> <div> Sucking and swallowing should be well developed.</div> <div> First stool is meconium for first 24 hours.</div> <div> Rectal temp to see if anus is patent.</div> <div> Intestines are sterile.</div> <div> Formula helps normal flora to come into stomach which produces vitamin K.</div> <div> Vitamin K has to be injected when first <FONT SIZE="3" COLOR="#800000" FACE="Arial" >born</FONT>.</div> <div> <U>Hepatic System</U>.</div> <div> Liver is immature. Its functions are to store iron, CHO metabolism, and blood coagulation.</div> <div> <U>Skin</U>.</div> <div> Assess color. There could be mottling or <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> (1st day = biliary obstruction).</div> <div> Assess for breaks in the skin, bruising (because of delivery) and vernix.</div> <div> About <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Jaundice</FONT>: It progresses head-to-toe. Can press on forehead and if blanch is yellow = <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT>. If a baby is <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> within 1st 24 hours = <B>pathological </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>jaundice</B></FONT><B>. </B>Most common cause is <U>ABO incompatibility</U>. Usually mom is O and baby is A or B. If <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> appears at about 2-3 days after birth it is <B>physiological </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>jaundice</B></FONT><B>. </B>Caused by an immature liver. Also called <I>icterus neonatorum. </I>When baby is <FONT SIZE="3" COLOR="#800000" FACE="Arial" >born</FONT>, it has a high erythrocyte count. When lungs become functional, some if the RBC's are not needed so they break down (they have a shorter life span than an adult anyway) into bilirubin. Bilirubin goes to the liver. Bilirubin loves to deposit in fatty tissue. If it builds to a dangerous level = <B>kernicterus</B> and causes brain damage. In an adult, bilirubin changes from being fat solable to being water soluble and leaves the body thru urine. In an infant, the liver is immature and is unable to change to water-soluble form and bilirubin levels sometimes go up. Do not get <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> until level gets to be <B>5mg</B>. Physiological <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> usually resolves itself in 7 to 10 days. Get rid of it by increasing urine output by increasing fluids. At <B>14mg</B>, will treat <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> with <I>phototherapy</I>. Purpose = the rays help change the bilirubin to a water soluble form to be excreted in urine.</div> <div> Precautions:</div> <div> Only wear a diaper.</div> <div> Protect eyes.</div> <div> Change position frequently.</div> <div> Document how far ray is away and how much.</div> <div> Check temp.</div> <div> Urine should look darker (tea color).</div> <div> Adequate fluid intake.</div> <div> Levels >20mg/dl = kernicterus.</div> <div> Home treatment: lie near window close to sun.</div> <div> Breast fed babies bilirubin may go up and should be monitored closely because of a substance in breast milk that breaks down bilirubin to a fat soluble form.</div> <div> Full term baby skin:</div> <div> Dry, peeling of hands and feet.</div> <div> Check skin turgor over abdomen.</div> <div> Vernix in creases.</div> <div> Lanugo in patches.</div> <div> <I>Harlequin sign</I>: normal variation where one side of baby's body is red and is due to vasomotor instability.</div> <div> <U>Musculoskeletal</U>.</div> <div> Assess muscle tone.</div> <div> Should have arms and legs flexed.</div> <div> Sometimes tremors or extremities shaking.</div> <div> Flacid, frog-legged, or extended extremities need to be investigated.</div> <div> Lethargic: needs stimulation for activity.</div> <div> Listless: just lying there.</div> <div> <U>Immune system</U>.</div> <div> Antiobodies IgG from placenta used for about 2 months and while breast feeding. </div> <div> Give immunity to polio, tetanus, chicken pox, pertussis and diptheria.</div> <div> <U>Urinary system</U>.</div> <div> Excreting CO2 thru the placenta and kidneys are not mature.</div> <div> Have difficulty concentrating urine and retaining electrolytes, and excreting medications.</div> <div> Should void within 24-48 hours and be sure to document.</div> <div> <U>Thermoregulation</U>.</div> <div> Very important.</div> <div> Loses heat when crying.</div> <div> 4 mechanisms of heat loss:</div> <div> Evaporation à lose heat and fluid when wet. We dry off baby when it comes out. </div> <div> Convection à moving air is a way to lose heat. Giving cold oxygen. Put on a warm bed. </div> <div> Conduction à cold from one surface to another. Touching baby with something cold will make it cold, such as a stethoscope or our hands. </div> <div> Radiation à radiate from surfaces around them. From one object to another, but does not touch.</div> <div> <B>Cold Stress</B></div> <div> Will use up calories and oxygen.</div> <div> S&S:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cold extremities </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">mottling </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">change in LOC </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">apnea (no breathing for >20 sec) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">suck poorly</div> <div> Cold stress is the metabolic demands placed on the neonate to maintain adequate body heat. When the neonate gets cold, receptors sends a message to the hypothalamus (responsible for coordinating heat loss and heat production) which sends a message to the sympathetic nervous system to activate heat production thru a process called <U>thermogenesis</U>. This is a <I>non-shivering</I> process. This method is produced by brown fat (unique to neonates). It is specialized tissue that is highly vascular and produces heat in the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >newborn</FONT>. Located in adipose tissue of axillary, above kidney, sternum, across shoulders, and nape of neck.</div> <div> If under cold stress, baby uses more oxygen and glucose and may become hypoxic. Respiratory distress and metabolic acidosis will occur. Acidosis of cold stress results in decreased production of surfactant.</div> <div> Respiratory distress symptoms:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">nasal flaring </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">retractions </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tachypnea (80bpm or greater) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tachycardia (>160) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">grunting</div> <div> Preventing neonate heat loss:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dry the neonate thoroughly with warm blankets immediately after birth </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dry head and cover to prevent heat loss through evaporation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Remove neonate from wet linens; avoid contact with wet linens </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Protect neonate from drafts from air conditioners, doors, or windows </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Maintain warm environment with radiant warmer </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Warm oxygen before administration </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Place a warm blanket between the neotate’s body and scales or any other cool surface </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Encourage skin-to-skin contact with mother after neonate is dried; mother’s body heat will warm <FONT SIZE="3" COLOR="#800000" FACE="Arial" >newborn</FONT> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preheat all materials and equipment that come in contact with neonate, such as blankets, hats, shirts, stethoscope, and hands </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Perform all procedures for which the neonate must be unwrapped as quickly as possible; rewrap immediately </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Remove cribs, isolettes, or radiant warmers form outside walls or windows </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Use double-walled isolettes for very low birth weight babies</div> <div> Baby will assume the fetal position to decrease body surface area and conserve heat.</div> <div> <B>Neonatal Behavior</B></div> <div> Reactivity à 15-30 minutes after birth. Heart rate is 160-180, RR is 60, looking around, not crying. </div> <div> Quiet stage à will doze for 2-3 hours. Vitals are at a resting stage. </div> <div> Reactivity again.</div> <div> <B>Apgar Scoring</B></div> <div> Heart rate</div> <div> Respiratory rate</div> <div> Muscle tone</div> <div> Reflexes</div> <div> Color</div> <div> Each category has a score of 2. 10 is highest although no baby usually is a 10. During this also check for obvious deformities.</div> <div> <B>Vital signs</B> abdomen should rise and fall</div> <div> Respirations:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">30-60 bpm </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">unlabored </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rise and fall symmetrically </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">slight irregularity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">clear bilaterally</div> <div> Heart rate:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4th and 5th intercostal space </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">120-160 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bradycardia if <100 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tachycardia if >160</div> <div> Temperature:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">axillary after initial rectal </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">above 97 (report if below)</div> <div> Weight:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">should be naked </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">scales should be balanced </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">average is 5.8-8.13 (2500g-4000g) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lose 5-10% of body weight the first few days</div> <div> Length: 45-55cm or 17.75-21.5 inches.</div> <div> Preterm = <37 weeks</div> <div> Term = 38-42 weeks</div> <div> Post term = >42 weeks</div> <div> Senses:</div> <div> Vision - can see a foot from their face. They like black on white.</div> <div> Hearing - will turn head to sound. Startles easily. Heart rate goes up. Likes being talked to.</div> <div> Acute smelling.</div> <div> Taste - likes sweet fluids vs. salty fluids. Sensitive to touch. Soothed by rocking and body contact. Like to be stroked and rubbed. Responds to pain.</div> <bR> </td> </tr></table></body>