WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:47.109 fast. Welcome to the emergency room. Welcome 00:00:47.109 --> 00:00:50.789 back to the deep dive. So if you're gearing up 00:00:50.789 --> 00:00:53.750 for your pediatric rotation or maybe that big 00:00:53.750 --> 00:00:57.090 PEDS exam is just looming, this one is absolutely 00:00:57.090 --> 00:01:00.600 for you. we are going straight into, I would 00:01:00.600 --> 00:01:06.000 argue, the most foundational and dynamic period 00:01:06.000 --> 00:01:08.040 of a person's life. Oh, for sure. The infant. 00:01:08.099 --> 00:01:10.060 We're talking from about two days old all the 00:01:10.060 --> 00:01:12.500 way up to one year. And it really is biology 00:01:12.500 --> 00:01:15.040 just in hyperdrive. I mean, the amount of change 00:01:15.040 --> 00:01:17.290 that happens in that first year is unlike anything 00:01:17.290 --> 00:01:19.730 else. It's staggering. Our goal today isn't just 00:01:19.730 --> 00:01:21.810 to, you know, list off facts from a textbook. 00:01:21.810 --> 00:01:24.510 We want to synthesize them. Really need to get 00:01:24.510 --> 00:01:27.450 past memorization and into the why. The clinical 00:01:27.450 --> 00:01:30.170 reasoning. Exactly. Why is the timing of that 00:01:30.170 --> 00:01:32.530 pincer grasp a direct safety issue? Why do we 00:01:32.530 --> 00:01:35.150 even have to use an adjusted age for preemies? 00:01:35.370 --> 00:01:37.629 It's all about connecting the physiology to what 00:01:37.629 --> 00:01:39.409 you do at the bedside. Right, connecting those 00:01:39.409 --> 00:01:41.709 dots. And we've pulled everything together, the 00:01:41.709 --> 00:01:44.590 vitals, growth, safety, the full immunization 00:01:44.590 --> 00:01:46.930 schedule, to really give you that high -yield 00:01:46.930 --> 00:01:49.230 80 -20 view of what you absolutely have to know. 00:01:49.709 --> 00:01:52.530 And that context is key. Everything, and I mean 00:01:52.530 --> 00:01:55.849 every system, neuro, respiratory, cardiovascular, 00:01:56.010 --> 00:01:58.609 it's all starting out profoundly immature. The 00:01:58.609 --> 00:02:00.969 whole year is this race toward functionality. 00:02:01.530 --> 00:02:04.290 If you keep that in mind, every assessment you 00:02:04.290 --> 00:02:06.730 make is going to be so much sharper. So let's 00:02:06.730 --> 00:02:09.110 jump right in where every single PEDS visit starts. 00:02:09.909 --> 00:02:12.849 The numbers. The numbers game. High -yield growth 00:02:12.849 --> 00:02:15.439 and vital signs. Okay, so when you're looking 00:02:15.439 --> 00:02:18.680 at an infant's chart, that rate of growth, it's 00:02:18.680 --> 00:02:20.919 something you have to know cold. Let's start 00:02:20.919 --> 00:02:23.259 with weight. Average birth weight is what, about 00:02:23.259 --> 00:02:25.479 seven and a half pounds? Yeah, around 3 ,400 00:02:25.479 --> 00:02:28.599 grams, 7 .5 pounds, but there are two rules about 00:02:28.599 --> 00:02:30.759 weight you just can't compromise on. The first 00:02:30.759 --> 00:02:33.020 one happens right away. Infants will lose up 00:02:33.020 --> 00:02:35.000 to 10 % of their birth weight in those first 00:02:35.000 --> 00:02:36.960 few days. And that's normal, right? That's not 00:02:36.960 --> 00:02:39.219 a panic moment. Totally normal. It's mostly fluid 00:02:39.219 --> 00:02:42.120 shifts, figuring out, feeding, all that, but... 00:02:42.169 --> 00:02:44.469 and this is the non -negotiable part, they must 00:02:44.469 --> 00:02:47.110 regain that weight by day 10 to 14. So if they 00:02:47.110 --> 00:02:49.289 haven't? If they haven't, that's an immediate 00:02:49.289 --> 00:02:51.490 red flag. You're thinking about feeding problems, 00:02:51.729 --> 00:02:54.530 hydration, maybe an underlying illness. That 00:02:54.530 --> 00:02:57.530 needs a full workup right away. And what's the 00:02:57.530 --> 00:02:59.830 second big rule? The one that's on like every 00:02:59.830 --> 00:03:02.530 exam? This is the one. They double their birth 00:03:02.530 --> 00:03:05.550 weight by five to six months. Double it. And 00:03:05.550 --> 00:03:09.340 they triple it by one year. Wow, I mean think 00:03:09.340 --> 00:03:11.699 about that if you're looking at a 12 month old 00:03:11.699 --> 00:03:14.240 who hasn't tripled their birth weight your brain 00:03:14.240 --> 00:03:17.120 should immediately be thinking Failure to thrive 00:03:17.120 --> 00:03:21.259 something is wrong. Yeah, that rule is pure high 00:03:21.259 --> 00:03:23.719 yield pets. Okay, so that's weight What about 00:03:23.719 --> 00:03:26.780 length average at birth is about 20 inches or 00:03:26.780 --> 00:03:28.699 50 centimeters, right? And the length increase 00:03:28.699 --> 00:03:31.719 is also really dramatic But not quite as explosive 00:03:31.719 --> 00:03:34.159 as the weight by the end of that first year their 00:03:34.159 --> 00:03:37.039 length has increased by about 50 percent So a 00:03:37.039 --> 00:03:39.620 20 -inch baby becomes a 30 -inch toddler. Basically, 00:03:39.800 --> 00:03:41.560 yeah. And just like with weight, you're tracking 00:03:41.560 --> 00:03:44.520 that curve. Any sudden drop off from their percentile 00:03:44.520 --> 00:03:46.500 is a sign that something might be up, like an 00:03:46.500 --> 00:03:48.319 endocrine issue. Now, for the one that really 00:03:48.319 --> 00:03:51.319 tells the story of that first year, head circumference. 00:03:52.099 --> 00:03:54.979 Why is this measurement so critical in infancy? 00:03:55.210 --> 00:03:57.629 It's all about the brain. I mean, the brain is 00:03:57.629 --> 00:04:00.370 growing at this absolutely exponential rate. 00:04:01.050 --> 00:04:03.849 An average head circumference at birth is around 00:04:03.849 --> 00:04:07.129 33 to 35 centimeters. OK. In the first year, 00:04:07.270 --> 00:04:10.550 it grows by about 10 centimeters total. But here 00:04:10.550 --> 00:04:13.250 is the key detail. It is heavily front loaded. 00:04:13.969 --> 00:04:16.230 The fastest growth is in the first six months. 00:04:16.329 --> 00:04:19.000 We're talking almost a centimeter a month. So 00:04:19.000 --> 00:04:20.720 if you see that measurement suddenly fall off 00:04:20.720 --> 00:04:23.300 the curve at, say, four months. You're worried. 00:04:23.439 --> 00:04:25.699 You're thinking about things like microcephaly, 00:04:25.860 --> 00:04:28.639 maybe poor brain growth. And on the flip side, 00:04:28.899 --> 00:04:31.160 if you see a sudden spike... Chondrocephalus. 00:04:31.310 --> 00:04:34.310 Right. Increased intracranial pressure. That's 00:04:34.310 --> 00:04:36.310 why you measure head circumference at every single 00:04:36.310 --> 00:04:38.930 well child visit until they're two. It's a vital 00:04:38.930 --> 00:04:41.410 sign for the brain. This leads us perfectly into 00:04:41.410 --> 00:04:44.050 a topic that exam writers just love. Oh yeah. 00:04:44.170 --> 00:04:46.550 The fontanels. The soft spots. You have to know 00:04:46.550 --> 00:04:49.310 their closing times. They exist for a reason. 00:04:49.410 --> 00:04:52.370 To let the head mold during birth. And, more 00:04:52.370 --> 00:04:54.870 importantly, to allow for that rapid brain growth 00:04:54.870 --> 00:04:56.870 we just talked about. So they're two main ones. 00:04:57.129 --> 00:05:00.680 Right. The posterior fontanelle, that's the smaller 00:05:00.680 --> 00:05:03.899 one in the back, it closes up really early, usually 00:05:03.899 --> 00:05:05.819 by two months of age. OK, so that one's gone 00:05:05.819 --> 00:05:08.819 pretty quick. Gone quick. But the anterior fontanelle, 00:05:08.819 --> 00:05:11.879 the big diamond -shaped one on top, that one 00:05:11.879 --> 00:05:14.139 stays open for much, much longer. To accommodate 00:05:14.139 --> 00:05:16.579 all that brain growth. Exactly. It typically 00:05:16.579 --> 00:05:20.019 closes sometime between 12 and 18 months. So 00:05:20.019 --> 00:05:22.579 if you're assessing a 10 -month -old, you should 00:05:22.579 --> 00:05:25.920 absolutely feel a soft, open anterior fontanelle. 00:05:25.959 --> 00:05:28.699 And if it's closed early. That's a problem called 00:05:28.699 --> 00:05:31.699 craniosynostosis. The skull is fusing too soon, 00:05:31.720 --> 00:05:34.680 and it can restrict brain growth. That's a neurosurgery 00:05:34.680 --> 00:05:36.920 consult. So when you're feeling that fontanelle, 00:05:37.319 --> 00:05:39.579 you want it to be soft and flat. But what if 00:05:39.579 --> 00:05:43.000 it's sunken or bulging? Great question. A sunken 00:05:43.000 --> 00:05:46.399 fontanelle screams dehydration. A bulging, tense 00:05:46.399 --> 00:05:49.079 fontanelle suggests increased intracranial pressure. 00:05:49.500 --> 00:05:51.579 But you have to assess it when the baby is calm 00:05:51.579 --> 00:05:54.120 and upright. Because crying can make it bulge 00:05:54.120 --> 00:05:56.370 temporarily. Right. crying can throw you off, 00:05:56.730 --> 00:05:59.029 so a calm sitting baby with a bulging fontanelle 00:05:59.029 --> 00:06:01.269 is a major concern. Okay, let's talk about putting 00:06:01.269 --> 00:06:03.350 it all together on the growth charts and this 00:06:03.350 --> 00:06:05.759 concept of adjusted age. The key with growth 00:06:05.759 --> 00:06:07.639 charts is the trend. It's not about a single 00:06:07.639 --> 00:06:11.360 number. A kid who is consistently on the 10th 00:06:11.360 --> 00:06:13.519 percentile is probably just a smaller, healthy 00:06:13.519 --> 00:06:16.259 kid. The red flag is the change. Exactly. The 00:06:16.259 --> 00:06:19.100 red flag is the kid who was on the 75th percentile 00:06:19.100 --> 00:06:21.459 and over two visits has dropped to the 15th. 00:06:21.459 --> 00:06:23.740 That kind of drop demands a full investigation. 00:06:23.980 --> 00:06:26.740 And for our preemies, we have to adjust their 00:06:26.740 --> 00:06:29.019 developmental clock, right? You have to. This 00:06:29.019 --> 00:06:32.319 is a just stage. For any baby born before 36 00:06:32.319 --> 00:06:35.399 weeks, you have to assess their milestones based 00:06:35.399 --> 00:06:37.600 on their due date, not their birth date. How 00:06:37.600 --> 00:06:39.639 do you calculate that? It's pretty simple. You 00:06:39.639 --> 00:06:41.480 take their chronological age, how old they are 00:06:41.480 --> 00:06:43.660 in months, and subtract the number of months 00:06:43.660 --> 00:06:46.500 they were premature. So a six month old who was 00:06:46.500 --> 00:06:48.519 born two months early. You assess them as a four 00:06:48.519 --> 00:06:51.220 month old. You got it. It prevents us from mislabeling 00:06:51.220 --> 00:06:53.899 a healthy preemie as delayed and gives parents 00:06:53.899 --> 00:06:57.139 realistic expectations. OK, that's physical size. 00:06:57.449 --> 00:06:59.629 Let's shift to how the body actually functions. 00:07:00.149 --> 00:07:02.529 We said all their systems are immature. How does 00:07:02.529 --> 00:07:04.910 that show up in their vitals? It means they have 00:07:04.910 --> 00:07:07.410 very little reserve. Their metabolism is sky 00:07:07.410 --> 00:07:09.870 high, their systems are inefficient, and they 00:07:09.870 --> 00:07:12.730 compensate for everything by going fast. Rate 00:07:12.730 --> 00:07:15.290 over strength. That's why their heart rate and 00:07:15.290 --> 00:07:17.230 respiratory rate are so high. Let's start with 00:07:17.230 --> 00:07:19.899 pulse rate. For a newborn, it's high, like 110 00:07:19.899 --> 00:07:23.639 to 160 beats per minute. For an infant up to 00:07:23.639 --> 00:07:26.279 a year, it settles a tiny bit, but it's still 00:07:26.279 --> 00:07:29.240 fast, maybe 90 to 160. And a low heart rate is 00:07:29.240 --> 00:07:32.680 the real danger. Oh, absolutely. In PIDS, bradycardia, 00:07:32.819 --> 00:07:35.000 a heart rate under 90 for an infant is a huge 00:07:35.000 --> 00:07:38.060 emergency. It often happens right before respiratory 00:07:38.060 --> 00:07:41.970 arrest. High is usually OK. Low is a crisis. 00:07:42.290 --> 00:07:44.170 What about respirations? This is where students 00:07:44.170 --> 00:07:46.029 get nervous thinking about the adult rate of 00:07:46.029 --> 00:07:49.329 12 to 20. Right. A newborn breathes 30 to 60 00:07:49.329 --> 00:07:52.209 times a minute. It slows to maybe 25 to 30 for 00:07:52.209 --> 00:07:54.810 an older infant. But the key thing to assess 00:07:54.810 --> 00:07:57.350 isn't just the number. It's how they're breathing. 00:07:57.910 --> 00:08:00.149 What do you mean? They are obligate abdominal 00:08:00.149 --> 00:08:02.209 breathers. They use their diaphragm because their 00:08:02.209 --> 00:08:03.970 chest muscles are weak. You'll see their belly 00:08:03.970 --> 00:08:06.370 go up and down. And their breathing pattern is 00:08:06.370 --> 00:08:08.769 often irregular. Little bursts of fast breathing, 00:08:08.870 --> 00:08:11.550 then a pause. That's normal. So what's the difference 00:08:11.550 --> 00:08:14.629 between that normal irregular breathing and actual 00:08:14.629 --> 00:08:16.730 respiratory distress? It's all about the work 00:08:16.730 --> 00:08:20.709 of breathing. Are you seeing nasal flaring where 00:08:20.709 --> 00:08:22.930 they're widening their nostrils to get more air 00:08:22.930 --> 00:08:25.709 in? Are you seeing retractions where the skin 00:08:25.709 --> 00:08:28.389 is sucking in between or under the ribs? Are 00:08:28.389 --> 00:08:30.769 you hearing grunting? Those are the signs of 00:08:30.769 --> 00:08:32.769 distress. Those are the signs that they are failing. 00:08:32.950 --> 00:08:35.370 Their tiny airways can get clogged so easily, 00:08:35.649 --> 00:08:38.370 so any increased work of breathing is an emergency. 00:08:38.649 --> 00:08:40.610 And this all ties back to those other immature 00:08:40.610 --> 00:08:43.110 systems, right? Like their renal and hematopoietic 00:08:43.110 --> 00:08:45.909 systems. It does. Their kidneys are terrible 00:08:45.909 --> 00:08:48.350 at concentrating urine, so they get dehydrated 00:08:48.350 --> 00:08:52.070 or fluid overloaded really easily. And hematologically, 00:08:52.250 --> 00:08:54.610 their fetal hemoglobin is being replaced, and 00:08:54.610 --> 00:08:57.389 their mom's iron stores run out around six months. 00:08:57.610 --> 00:09:00.730 Which is why we see physiologic And why iron 00:09:00.730 --> 00:09:02.769 -fortified cereals and foods are so important 00:09:02.769 --> 00:09:05.190 once they start solids? Everything is just getting 00:09:05.190 --> 00:09:07.429 started. This is a perfect setup for blood pressure, 00:09:07.830 --> 00:09:10.309 because this is where PEDS is a totally different 00:09:10.309 --> 00:09:13.129 world from adults. It really is. An infant's 00:09:13.129 --> 00:09:15.110 blood pressure is the lowest it will ever be 00:09:15.110 --> 00:09:18.350 in their life. Average systolic is maybe 85, 00:09:18.850 --> 00:09:21.129 but here's the thing you cannot forget. Okay. 00:09:21.370 --> 00:09:24.529 Infants are masters of compensation. If they're 00:09:24.529 --> 00:09:27.009 going into shock, they will squeeze their peripheral 00:09:27.009 --> 00:09:29.350 blood vessels and crank up their heart rate to 00:09:29.350 --> 00:09:31.710 maintain that blood pressure until the very last 00:09:31.710 --> 00:09:34.029 second. So if you see the blood pressure drop, 00:09:34.230 --> 00:09:37.350 you're already behind. A drop in BP is a late 00:09:37.350 --> 00:09:40.250 and catastrophic sign of shock in a child. By 00:09:40.250 --> 00:09:42.529 the time their BP falls, their body's compensation 00:09:42.529 --> 00:09:44.350 has already failed. So you have to catch the 00:09:44.350 --> 00:09:47.250 early signs. The early signs. Tachycardia, poor 00:09:47.250 --> 00:09:49.870 perfusion -like cool skin, and a cap refill over 00:09:49.870 --> 00:09:52.230 three seconds, and a change in mental status. 00:09:52.570 --> 00:09:54.909 Don't wait for the BP to drop. Got it. Okay, 00:09:55.269 --> 00:09:57.450 rounding out this section. Temperature and pain. 00:09:57.639 --> 00:09:59.740 Temperature is pretty straightforward. It can 00:09:59.740 --> 00:10:02.779 be a little higher normally, maybe 99 .5 Fahrenheit 00:10:02.779 --> 00:10:07.100 or 37 .5 Celsius axillary. We use axillary for 00:10:07.100 --> 00:10:09.600 screening. Rectal is the gold standard for a 00:10:09.600 --> 00:10:11.820 core temp, but we only do it when absolutely 00:10:11.820 --> 00:10:14.200 necessary, especially in young infants. And since 00:10:14.200 --> 00:10:16.230 they can't tell you they're in pain... We have 00:10:16.230 --> 00:10:18.809 to be detectives. We use objective scales. The 00:10:18.809 --> 00:10:20.970 classic one for newborns and young infants is 00:10:20.970 --> 00:10:23.389 the CRY -S scale. What does that stand for? It's 00:10:23.389 --> 00:10:26.990 an acronym. CRY requires O2, increased vital 00:10:26.990 --> 00:10:29.950 signs, expression, and sleeplessness. And you 00:10:29.950 --> 00:10:32.610 see, vitals are built right into the score. If 00:10:32.610 --> 00:10:35.990 their heart rate or BP is up more than 20%, that's 00:10:35.990 --> 00:10:38.470 a sign of pain. It's a combination of behavior 00:10:38.470 --> 00:10:41.210 and physiology. This is a ton of great detail. 00:10:41.330 --> 00:10:44.019 Let's try to boil it down. Let's do it. So what 00:10:44.019 --> 00:10:47.000 nurses are watching for in this section? You're 00:10:47.000 --> 00:10:50.960 watching for any big drop across growth percentiles. 00:10:51.100 --> 00:10:53.720 You're watching for a failure to regain birth 00:10:53.720 --> 00:10:56.240 weight. And with vitals, you're watching for 00:10:56.240 --> 00:10:58.740 any sign of increased work of breathing retractions, 00:10:58.980 --> 00:11:01.179 flaring, grunting. And for the students, what 00:11:01.179 --> 00:11:03.980 do exam writers love to test? Oh, they love the 00:11:03.980 --> 00:11:06.820 fontanel closure times. Anterior is 12 to 18 00:11:06.820 --> 00:11:09.440 months. Posterior is two months. They love the 00:11:09.440 --> 00:11:11.740 weight rule double by six months, triple by 12. 00:11:12.279 --> 00:11:14.620 And they will absolutely test you on knowing 00:11:14.620 --> 00:11:17.299 that a drop in blood is a late, terrible sign 00:11:17.299 --> 00:11:19.080 of shock. And our memory trick for this whole 00:11:19.080 --> 00:11:22.500 age group. The infant is all about triple growth 00:11:22.500 --> 00:11:26.440 weight triples, length up by 50%, and high H 00:11:26.440 --> 00:11:29.980 vibes, high normal heart rate, and respiratory 00:11:29.980 --> 00:11:33.200 rate. Okay, we have the numbers down. Now let's 00:11:33.200 --> 00:11:37.639 get into the action. milestones how infants master 00:11:37.639 --> 00:11:40.799 the world understanding this sequence is I mean 00:11:40.799 --> 00:11:43.179 it's everything for safety counseling it is the 00:11:43.179 --> 00:11:45.639 scaffolding for everything else you do and it 00:11:45.639 --> 00:11:48.980 follows two very predictable rules this isn't 00:11:48.980 --> 00:11:52.379 random okay what are the rules first gross motor 00:11:52.379 --> 00:11:55.500 skills develop suffocato head -to -toe head -to 00:11:55.500 --> 00:11:57.960 -toe they control their head then their trunk 00:11:57.960 --> 00:12:00.120 then their legs it's like building a power from 00:12:00.120 --> 00:12:02.799 the top down and the second rule Fine motor skills 00:12:02.799 --> 00:12:05.659 develop proximodistal. Center out to the periphery. 00:12:05.840 --> 00:12:08.100 Exactly. They control their shoulder and arm 00:12:08.100 --> 00:12:10.320 before they can control their wrist and fingers. 00:12:10.659 --> 00:12:12.419 You have to be able to swing the whole bat before 00:12:12.419 --> 00:12:14.320 you can write your name. That makes perfect sense. 00:12:14.440 --> 00:12:16.080 So let's walk through that roadmap. Let's hit 00:12:16.080 --> 00:12:19.960 the big four. Two, four, six, nine, and 12 months. 00:12:20.039 --> 00:12:22.360 Right. At two months, they're just starting to 00:12:22.360 --> 00:12:24.559 fight gravity. They can lift their head a little 00:12:24.559 --> 00:12:25.980 bit when they're on their tummy. The beginning 00:12:25.980 --> 00:12:28.570 of head control. The very beginning. Then at 00:12:28.570 --> 00:12:31.370 four months, that's the big head control milestone. 00:12:31.909 --> 00:12:34.370 They can hold their head steady without any support. 00:12:34.730 --> 00:12:37.549 This is huge. If a baby can't do this by four 00:12:37.549 --> 00:12:39.929 months, that's a developmental red flag. Right. 00:12:39.990 --> 00:12:41.950 And at six months, things really get moving. 00:12:42.370 --> 00:12:44.730 Six months is the rolling age. They can roll 00:12:44.730 --> 00:12:47.389 all the way over front to back and back to front. 00:12:47.669 --> 00:12:49.809 This is when your safety antenna has to go way 00:12:49.809 --> 00:12:53.309 up for falls. They also start sitting. But with 00:12:53.309 --> 00:12:55.570 help, right? Yeah, they can often sit in a tripod 00:12:55.570 --> 00:12:57.870 position using their hands out front for support. 00:12:58.129 --> 00:13:00.710 And then nine months is the magic number for 00:13:00.710 --> 00:13:02.909 sitting independently. Yes, independent sitting. 00:13:03.289 --> 00:13:05.470 They can sit up unsupported and they can get 00:13:05.470 --> 00:13:07.850 themselves into a sitting position. This is also 00:13:07.850 --> 00:13:09.730 when they start pulling up to stand on furniture. 00:13:10.090 --> 00:13:11.830 The beginning of cruising. The beginning of cruising, 00:13:11.970 --> 00:13:14.350 which leads us to 12 months. This is the full 00:13:14.350 --> 00:13:16.970 mobility age. They are pulling to stand easily, 00:13:17.049 --> 00:13:19.549 cruising all over the place, and many are taking 00:13:19.549 --> 00:13:22.440 their first independent steps. A 12 -month -old 00:13:22.440 --> 00:13:25.419 is basically a pre -toddler. OK, so that's the 00:13:25.419 --> 00:13:28.360 big body movements. Let's track the hands, the 00:13:28.360 --> 00:13:30.679 fine motor skills. At two months, their hands 00:13:30.679 --> 00:13:33.740 are still mostly reflexive. But by four months, 00:13:33.820 --> 00:13:36.519 you see purpose. They're batting at toys, bringing 00:13:36.519 --> 00:13:38.860 their hands to their mouth, exploring. At six 00:13:38.860 --> 00:13:41.610 months. They start reaching and grabbing with 00:13:41.610 --> 00:13:44.029 intent. Real intent. They see something they 00:13:44.029 --> 00:13:46.190 want and they go for it. In around seven months, 00:13:46.210 --> 00:13:48.190 they can transfer an object from one hand to 00:13:48.190 --> 00:13:50.830 the other. That's a huge cognitive and motor 00:13:50.830 --> 00:13:52.929 leap. Now for the two that are always on exams, 00:13:54.230 --> 00:13:57.059 the pins are grasps. Nine months versus 12 months. 00:13:57.200 --> 00:13:59.960 At nine months, they get the gross pincer grasp. 00:14:00.039 --> 00:14:01.960 Think of it like a rake. They use their whole 00:14:01.960 --> 00:14:04.139 hand and all their fingers to rake an object 00:14:04.139 --> 00:14:07.120 toward them. It's clumsy, but effective. And 00:14:07.120 --> 00:14:09.679 then the refinement happens. At 12 months, they 00:14:09.679 --> 00:14:13.419 achieve the fine pincer grasp. This is that beautiful, 00:14:13.539 --> 00:14:15.659 precise movement using the tip of the thumb and 00:14:15.659 --> 00:14:17.700 the tip of the index finger. The cheerio grasp. 00:14:17.779 --> 00:14:20.159 The cheerio grasp. It's essential for self -feeding, 00:14:20.240 --> 00:14:22.360 but as we'll see, it's also a direct line to 00:14:22.360 --> 00:14:25.279 a major safety hazard. So as nurses, we're tracking 00:14:25.279 --> 00:14:27.620 all this. But what are the big signs of developmental 00:14:27.620 --> 00:14:30.200 delay? When should we really be worried? The 00:14:30.200 --> 00:14:33.460 number one absolute biggest red flag is regression. 00:14:34.100 --> 00:14:36.879 Losing a skill they once had. That requires an 00:14:36.879 --> 00:14:39.620 immediate full neurologic workup. What about 00:14:39.620 --> 00:14:41.740 those primitive reflexes we all learn about? 00:14:42.080 --> 00:14:45.799 They have to disappear on time. The moro or startle 00:14:45.799 --> 00:14:48.480 reflex should be gone by about four months. If 00:14:48.480 --> 00:14:50.980 you see a strong moro reflex in a six or seven 00:14:50.980 --> 00:14:53.639 month old, that's a problem. Why? Because that 00:14:53.639 --> 00:14:55.779 involuntary reflex is getting in the way of voluntary 00:14:55.779 --> 00:14:58.039 movement. It's a sign the central nervous system 00:14:58.039 --> 00:15:00.679 isn't maturing correctly. And what about sensory 00:15:00.679 --> 00:15:03.679 and language delays? For hearing, if they're 00:15:03.679 --> 00:15:05.600 not turning to a sound by four months, that's 00:15:05.600 --> 00:15:08.100 a concern. For vision, if their eyes are still 00:15:08.100 --> 00:15:10.639 crossed most of the time past six months, that 00:15:10.639 --> 00:15:13.299 needs an evaluation. And language. We want to 00:15:13.299 --> 00:15:16.139 hear babbling, like da -da -da, by around eight 00:15:16.139 --> 00:15:18.240 months. And by 12 months, we hope to hear at 00:15:18.240 --> 00:15:20.759 least one or two single words used with meaning, 00:15:21.240 --> 00:15:24.340 like mama or da -da. So our job is to screen 00:15:24.340 --> 00:15:26.799 and refer, not diagnose. That's it. We use our 00:15:26.799 --> 00:15:28.480 tools, we use our observation, and we get them 00:15:28.480 --> 00:15:31.179 into early intervention if we spot a delay. OK, 00:15:31.200 --> 00:15:33.460 let's wrap this section. What are nurses watching 00:15:33.460 --> 00:15:36.600 for? You're watching for that loss of a milestone. 00:15:37.320 --> 00:15:39.759 Inability to hold the head steady by four months 00:15:39.759 --> 00:15:42.740 is a big one. Inability to sit alone by nine 00:15:42.740 --> 00:15:45.539 months and the persistence of those primitive 00:15:45.539 --> 00:15:48.039 reflexes. And what do exam writers love? The 00:15:48.039 --> 00:15:50.639 sequence. They love it. Head control at four, 00:15:50.759 --> 00:15:52.980 rolling at six, sitting at nine, cruising at 00:15:52.980 --> 00:15:55.940 12. And they love to have you differentiate between 00:15:55.940 --> 00:15:58.960 the gross pincer grasp at nine months and the 00:15:58.960 --> 00:16:01.559 fine pincer grasp at 12. And our memory phrase 00:16:01.559 --> 00:16:04.019 for motor development. Crawl before you walk 00:16:04.019 --> 00:16:07.179 and gross before fine. Okay, the body is moving, 00:16:07.600 --> 00:16:10.279 the senses are working. Let's dig into the mind 00:16:10.279 --> 00:16:13.210 and the heart. The infant psyche, cognitive, 00:16:13.490 --> 00:16:16.090 and psychosocial milestones. This is where we 00:16:16.090 --> 00:16:18.129 lay the foundation for learning and personality. 00:16:18.649 --> 00:16:20.889 For cognitive development, we have to talk about 00:16:20.889 --> 00:16:23.210 page debt. For infants, it's the sensorimotor 00:16:23.210 --> 00:16:25.230 stage. Learning through senses and movement. 00:16:25.590 --> 00:16:28.090 Exactly. It starts with just pure reflexes. But 00:16:28.090 --> 00:16:30.129 then from about one to four months, they hit 00:16:30.129 --> 00:16:32.769 what he called primary circular reactions. Which 00:16:32.769 --> 00:16:35.549 means? It means they're repeating actions centered 00:16:35.549 --> 00:16:37.690 on their own body just because it feels good, 00:16:37.769 --> 00:16:39.549 like sucking their thumb. They're discovering 00:16:39.549 --> 00:16:41.679 themselves. What's the big shift after that? 00:16:42.039 --> 00:16:45.039 From four to eight months, they move to secondary 00:16:45.039 --> 00:16:48.460 circular reactions. Now the focus is on the outside 00:16:48.460 --> 00:16:50.940 world. They shake a rattle on purpose to hear 00:16:50.940 --> 00:16:53.399 the sound. They kick a mobile to make it move. 00:16:53.500 --> 00:16:55.299 They realize they can have an effect on things. 00:16:55.440 --> 00:16:59.659 Yes. I did that. It's a huge cognitive leap. 00:17:00.159 --> 00:17:02.600 And that leads to truly purposeful action by 00:17:02.600 --> 00:17:05.539 8 to 12 months. They start to understand symbols, 00:17:05.619 --> 00:17:07.440 like when they see the bottle, they know they're 00:17:07.440 --> 00:17:09.900 about to eat. And this is where that classic, 00:17:10.400 --> 00:17:12.920 always -on -the -test concept emerges. Object 00:17:12.920 --> 00:17:15.160 permanence. You have to know this one. You do. 00:17:15.579 --> 00:17:18.039 It's the understanding that something still exists, 00:17:18.200 --> 00:17:20.980 even when you can't see it. Before this, it's 00:17:20.980 --> 00:17:23.640 literally out of sight, out of mind. This starts 00:17:23.640 --> 00:17:25.660 to develop around eight months of age. And that's 00:17:25.660 --> 00:17:27.319 so important for their emotional development, 00:17:27.500 --> 00:17:30.279 too. It's directly tied to it. Which brings us 00:17:30.279 --> 00:17:33.779 to Erickson. The psychosocial stage for the entire 00:17:33.779 --> 00:17:37.500 first year is trust versus mistrust. So how does 00:17:37.500 --> 00:17:41.039 an infant build trust? It's all about consistency 00:17:41.039 --> 00:17:43.799 and reliability. When the infant cries, does 00:17:43.799 --> 00:17:46.279 someone come? When they're hungry, are they fed? 00:17:46.759 --> 00:17:50.240 When they're wet, are they changed? If those 00:17:50.240 --> 00:17:53.039 needs are met reliably, They learn the world 00:17:53.039 --> 00:17:55.680 is a safe, predictable place. They build trust. 00:17:56.079 --> 00:17:58.619 And if not? They develop a fundamental sense 00:17:58.619 --> 00:18:01.059 of mistrust. They learn the world is chaotic 00:18:01.059 --> 00:18:04.119 and unreliable. As a nurse in the hospital, you 00:18:04.119 --> 00:18:06.660 build trust by responding to their cries, providing 00:18:06.660 --> 00:18:09.259 comfort, and keeping their parents close. And 00:18:09.259 --> 00:18:11.660 this connects directly to those common anxieties 00:18:11.660 --> 00:18:14.099 we see. The two big ones. First is separation 00:18:14.099 --> 00:18:16.700 anxiety. It starts around four to eight months. 00:18:16.779 --> 00:18:18.700 Once they have object permanence, they know you're 00:18:18.700 --> 00:18:20.480 gone and they don't like it. And the second one? 00:18:20.619 --> 00:18:23.440 which every nurse has experienced. Stranger anxiety 00:18:23.440 --> 00:18:26.779 or stranger fear. This pops up around seven to 00:18:26.779 --> 00:18:28.619 eight months and it's actually a good sign. It 00:18:28.619 --> 00:18:30.400 means their brain has developed enough to tell 00:18:30.400 --> 00:18:32.900 the difference between familiar people and strangers. 00:18:33.039 --> 00:18:34.680 So when they scream at you, you shouldn't take 00:18:34.680 --> 00:18:37.099 it personally. Not at all. The intervention is 00:18:37.099 --> 00:18:40.079 to go slow, talk softly, let the parent hold 00:18:40.079 --> 00:18:42.799 them, do the least invasive parts of your assessment 00:18:42.799 --> 00:18:45.980 first, respect their fear. Let's talk about how 00:18:45.980 --> 00:18:48.029 they learn through play. Play is their work. 00:18:48.250 --> 00:18:50.829 And for infants, it is almost entirely solitary 00:18:50.829 --> 00:18:53.609 play. They play alone, focused on their own sensory 00:18:53.609 --> 00:18:56.849 world. So what are some good age -appropriate 00:18:56.849 --> 00:18:59.630 toys? In early infancy, things that stimulate 00:18:59.630 --> 00:19:02.650 the senses. Rattles are perfect for those secondary 00:19:02.650 --> 00:19:05.970 circular reactions. Teething toys, soft toys. 00:19:06.450 --> 00:19:09.069 A mirror is fantastic for self -discovery around 00:19:09.069 --> 00:19:11.380 six months. And for the older infant. As they 00:19:11.380 --> 00:19:13.920 get that pincer grasp, simple blocks are great. 00:19:14.059 --> 00:19:16.619 Things they can stack and knock over cause an 00:19:16.619 --> 00:19:19.539 effect. The key in the hospital is that play 00:19:19.539 --> 00:19:22.279 is a nursing intervention. It's not just a distraction. 00:19:22.519 --> 00:19:25.480 It promotes normal development. Great. Let's 00:19:25.480 --> 00:19:27.759 summarize the psyche section. What are nurses 00:19:27.759 --> 00:19:30.079 watching for? You're watching for an infant who 00:19:30.079 --> 00:19:32.940 is just inconsolable, who doesn't respond to 00:19:32.940 --> 00:19:35.160 comfort. That could be a sign of illness or a 00:19:35.160 --> 00:19:38.480 failure to form trust. Also, a lack of babbling 00:19:38.480 --> 00:19:40.980 by eight months is a language red flag. And what 00:19:40.980 --> 00:19:43.619 do exam writers love? They love pairing the theorists. 00:19:43.920 --> 00:19:46.839 Erickson's trust versus mistrust goes with Pejat's 00:19:46.839 --> 00:19:49.680 sensory motor stage. And you absolutely must 00:19:49.680 --> 00:19:51.900 know the timing of object permanence, around 00:19:51.900 --> 00:19:54.240 eight months, and how it leads to separation 00:19:54.240 --> 00:19:56.440 anxiety. Our memory phrase for this one. Trust 00:19:56.440 --> 00:19:59.720 me, I'll find the object. for trust versus mistrust 00:19:59.720 --> 00:20:01.940 and object permanence. All right. We've got a 00:20:01.940 --> 00:20:04.400 growing, moving, thinking infant. Now we have 00:20:04.400 --> 00:20:07.940 to protect them. Let's move into protecting the 00:20:07.940 --> 00:20:10.720 infant immunizations and safety. This is where 00:20:10.720 --> 00:20:12.859 our knowledge of development becomes life -saving 00:20:12.859 --> 00:20:15.339 intervention. Let's start with the vaccine schedule. 00:20:15.680 --> 00:20:18.339 It's so complex. But there's a pattern, right? 00:20:18.460 --> 00:20:21.220 There is. For students, focus on the two -month, 00:20:21.359 --> 00:20:23.480 four -month, six -month pattern. Most of the 00:20:23.480 --> 00:20:25.920 core series happens then. Why so many shots so 00:20:25.920 --> 00:20:28.480 early? Two reasons. First, their own immune system 00:20:28.480 --> 00:20:30.920 is immature and needs multiple doses to build 00:20:30.920 --> 00:20:33.380 a strong memory. Second, the antibodies they 00:20:33.380 --> 00:20:35.839 got from mom and utero start to wear off, leaving 00:20:35.839 --> 00:20:38.019 them vulnerable. OK, so let's run through the 00:20:38.019 --> 00:20:40.400 high points. It starts at birth. At birth, they 00:20:40.400 --> 00:20:42.480 get their first dose of hepatitis B. Then the 00:20:42.480 --> 00:20:44.460 big one at two months. This is The Good Visit. 00:20:44.599 --> 00:20:48.339 They get DTaP -P, which is diphtheria, tetanus, 00:20:48.440 --> 00:20:50.900 and pertussis. They get rotavirus, which is an 00:20:50.900 --> 00:20:54.160 oral vaccine. They get Hib, pneumococcal, PCV, 00:20:54.259 --> 00:20:57.440 and polio, IPV. And their second dose of Hep 00:20:57.440 --> 00:21:01.339 B. Wow, that's a lot. And at four months? It's 00:21:01.339 --> 00:21:03.359 mostly a repeat. They get the second doses of 00:21:03.359 --> 00:21:07.240 DTaP, rotavirus, hep, PCV, and IPV. It's all 00:21:07.240 --> 00:21:09.920 about reinforcing that initial immune response. 00:21:10.160 --> 00:21:12.680 And it's six months. Another round to continue 00:21:12.680 --> 00:21:16.200 building immunity. DTaP, IPV, PCV, and usually 00:21:16.200 --> 00:21:19.279 the third doses of hep B and hep. And critically, 00:21:19.539 --> 00:21:21.700 after six months, they're now eligible for the 00:21:21.700 --> 00:21:23.819 annual flu shot. which is so important for their 00:21:23.819 --> 00:21:26.059 little respiratory systems. Absolutely vital. 00:21:26.259 --> 00:21:28.519 A nurse's job is to know the schedule, educate 00:21:28.519 --> 00:21:30.880 the parents, and monitor for reactions. OK, now 00:21:30.880 --> 00:21:33.380 let's connect development to risk. Injury prevention. 00:21:33.720 --> 00:21:36.059 Every single new milestone opens up a new way 00:21:36.059 --> 00:21:38.000 for them to get hurt. We have to anticipate it. 00:21:38.259 --> 00:21:40.519 Let's start with aspiration choking. So infants 00:21:40.519 --> 00:21:42.420 are in that oral stage. Everything goes in the 00:21:42.420 --> 00:21:44.440 mouth. But the risk goes through the roof once 00:21:44.440 --> 00:21:46.720 they get that fine pincer grasp around 12 months. 00:21:46.940 --> 00:21:49.039 Because now they can pick up the tiny things. 00:21:49.319 --> 00:21:52.519 The coin, the button, the piece of a dog food. 00:21:53.299 --> 00:21:56.079 The rule is, if an object can fit through a toilet 00:21:56.079 --> 00:21:59.079 paper tube, it's a choking hazard for an infant. 00:21:59.440 --> 00:22:03.339 Next up, falls. The risk starts the second they 00:22:03.339 --> 00:22:06.180 can roll, around six months. The rule is simple 00:22:06.180 --> 00:22:09.039 and absolute. Never leave an infant alone on 00:22:09.039 --> 00:22:12.259 a high surface. Not for a second. And what about 00:22:12.259 --> 00:22:14.940 the crib? Once they can pull to stand, that mattress 00:22:14.940 --> 00:22:17.720 has to go to the lowest possible setting. And 00:22:17.720 --> 00:22:20.119 we need to talk about baby walkers. The recommendation 00:22:20.119 --> 00:22:22.980 is to not use them. Do not use them. They give 00:22:22.980 --> 00:22:25.759 a mobile infant access to stairs and other hazards 00:22:25.759 --> 00:22:27.960 before they have the judgment or control to handle 00:22:27.960 --> 00:22:30.460 them. They are a major cause of serious injuries. 00:22:30.660 --> 00:22:33.740 OK, drowning in burns. An infant can drown in 00:22:33.740 --> 00:22:36.220 an inch of water. You need touch supervision 00:22:36.220 --> 00:22:39.339 in the bath at all times. For burns, turn your 00:22:39.339 --> 00:22:42.099 water heater down to 120 degrees Fahrenheit and 00:22:42.099 --> 00:22:44.779 never ever heat a bottle in the microwave. It 00:22:44.779 --> 00:22:47.579 creates dangerous hot spots. And poisoning? Once 00:22:47.579 --> 00:22:49.640 they're mobile crawling, cruising everything 00:22:49.640 --> 00:22:52.359 is a target. All cleaning supplies, all medications 00:22:52.359 --> 00:22:55.380 need to be locked up high and out of reach. Have 00:22:55.380 --> 00:22:57.400 the poison control numbers saved in your phone. 00:22:57.779 --> 00:23:00.380 Let's hit the big two for exams. First, motor 00:23:00.380 --> 00:23:03.289 vehicle safety. Non -negotiable. The car seat 00:23:03.289 --> 00:23:06.109 must be rear -facing in the back seat for as 00:23:06.109 --> 00:23:09.410 long as possible, at least until age two. This 00:23:09.410 --> 00:23:11.210 protects their fragile neck and spinal cord, 00:23:11.349 --> 00:23:13.710 and it has to be installed at a 45 -degree angle 00:23:13.710 --> 00:23:16.210 to keep their airway open. And the other big 00:23:16.210 --> 00:23:20.049 one, SID's prevention, the sleep environment. 00:23:20.410 --> 00:23:23.670 This is critical teaching. The mantra is, back 00:23:23.670 --> 00:23:26.140 to sleep. Always place the infant on their back 00:23:26.140 --> 00:23:29.279 in a crib with a firm mattress and nothing else. 00:23:29.480 --> 00:23:31.700 Nothing else. Nothing. No pillows, no bumper 00:23:31.700 --> 00:23:34.599 pads, no blankets, no stuffed animals. Just the 00:23:34.599 --> 00:23:37.220 baby in a sleep sack. A clear crib is a safe 00:23:37.220 --> 00:23:39.900 crib. So let's summarize protection. What are 00:23:39.900 --> 00:23:42.079 nurses watching for? You're watching for unsafe 00:23:42.079 --> 00:23:45.000 practices, an improperly installed car seat, 00:23:45.180 --> 00:23:47.740 a crib full of blankets, small toys left within 00:23:47.740 --> 00:23:50.000 reach of a newly mobile infant. And what do exam 00:23:50.000 --> 00:23:52.359 writers love to test? They love the safety triad. 00:23:52.440 --> 00:23:55.380 Back to sleep for SIs, rear -facing for car safety, 00:23:55.579 --> 00:23:57.779 and connecting that fine pincer grass directly 00:23:57.779 --> 00:24:00.079 to the choking hazard. Our memory phrase for 00:24:00.079 --> 00:24:02.180 infant safety. Everything goes in the mouth and 00:24:02.180 --> 00:24:04.779 they never stop moving. Okay, we've covered the 00:24:04.779 --> 00:24:07.799 body, the mind, and how to protect them. Let's 00:24:07.799 --> 00:24:10.359 wrap up with the day -to -day guidance. Nursing 00:24:10.359 --> 00:24:13.240 care, nutrition, sleep, and common concerns. 00:24:13.640 --> 00:24:15.539 The foundation of nutrition for the first year 00:24:15.539 --> 00:24:19.299 is simple. Breast milk or iron -fortified formula. 00:24:19.619 --> 00:24:22.180 That is their primary food. And we need to remember 00:24:22.180 --> 00:24:24.900 to supplement with vitamin D if they're exclusively 00:24:24.900 --> 00:24:27.960 breastfed. Yes, that's a key point. Human milk 00:24:27.960 --> 00:24:30.680 is low in vitamin D, so they need drops starting 00:24:30.680 --> 00:24:33.460 soon after birth. OK, so when do we introduce 00:24:33.460 --> 00:24:36.180 solid foods? The window is between four and six 00:24:36.180 --> 00:24:38.819 months, but it's based on developmental readiness, 00:24:39.140 --> 00:24:41.000 not just the calendar. What are those readiness 00:24:41.000 --> 00:24:43.400 cues? They need good head control, so they can 00:24:43.400 --> 00:24:45.599 sit up and eat. They need to show interest in 00:24:45.599 --> 00:24:48.420 food, and most importantly, that extrusion reflex, 00:24:48.859 --> 00:24:51.200 the tongue -thrust reflex that pushes food out, 00:24:51.240 --> 00:24:53.480 has to be gone. And the process of introducing 00:24:53.480 --> 00:24:56.619 foods is very specific. Very. You introduce one 00:24:56.619 --> 00:24:59.119 new, single ingredient food every three to four 00:24:59.119 --> 00:25:01.500 days. That way, if they have an allergic reaction, 00:25:01.700 --> 00:25:03.660 you know exactly what caused it. And we usually 00:25:03.660 --> 00:25:06.349 start with iron -fortified rice cereal. Typically, 00:25:06.710 --> 00:25:09.609 yes. Then you can move on to pureed vegetables 00:25:09.609 --> 00:25:11.869 and fruits. And remember, until they have enough 00:25:11.869 --> 00:25:14.369 teeth, which start coming in around six to 10 00:25:14.369 --> 00:25:16.690 months, everything needs to be soft and mashed. 00:25:17.569 --> 00:25:19.950 What about weaning from the bottle? You can introduce 00:25:19.950 --> 00:25:22.849 a cup around six months. The goal is to be off 00:25:22.849 --> 00:25:25.410 the bottle by 12 to 18 months to prevent dental 00:25:25.410 --> 00:25:29.349 caries and never, ever put a baby into bed with 00:25:29.349 --> 00:25:31.730 a bottle. Let's hit a few of those common concerns 00:25:31.730 --> 00:25:34.210 that stress parents out. Sure. Spitting up is 00:25:34.210 --> 00:25:36.400 normal. Just keep them upright for a bit after 00:25:36.400 --> 00:25:39.440 they eat. Colic, that intense crying, is awful, 00:25:39.480 --> 00:25:42.119 but it's temporary. It usually resolves by three 00:25:42.119 --> 00:25:44.279 months. And teething? Teething can make them 00:25:44.279 --> 00:25:46.740 fussy and mess with sleep. You can offer cool 00:25:46.740 --> 00:25:50.200 teething rings or a washcloth. For pain, acetaminophen 00:25:50.200 --> 00:25:54.019 is fine, but a key test point. No ibuprofen for 00:25:54.019 --> 00:25:56.519 infants under six months of age. Let's talk about 00:25:56.519 --> 00:25:59.059 sleep. What should parents expect? A newborn 00:25:59.059 --> 00:26:02.180 sleeps like 20 hours a day. But the big change 00:26:02.180 --> 00:26:04.140 happens around three to four months. Their sleep 00:26:04.140 --> 00:26:06.259 starts to consolidate. They might start sleeping 00:26:06.259 --> 00:26:08.420 a seven or eight hour stretch at night. And by 00:26:08.420 --> 00:26:11.099 12 months. They should be sleeping eight to 12 00:26:11.099 --> 00:26:13.140 hours at night with a couple of naps during the 00:26:13.140 --> 00:26:16.289 day. The best nursing intervention is to encourage 00:26:16.289 --> 00:26:19.630 a consistent, predictable bedtime routine starting 00:26:19.630 --> 00:26:21.829 around four months. It sounds like the nurse's 00:26:21.829 --> 00:26:24.549 role is constant anticipatory guidance. You are 00:26:24.549 --> 00:26:26.170 always preparing the parent for what's coming 00:26:26.170 --> 00:26:29.069 next. You assess milestones, you teach about 00:26:29.069 --> 00:26:31.309 safety, you guide them on nutrition and sleep. 00:26:31.750 --> 00:26:34.569 You are their trusted resource. Let's go find 00:26:34.569 --> 00:26:36.549 a wrap -up for this section. What are nurses 00:26:36.549 --> 00:26:38.819 watching for? You're watching for inappropriate 00:26:38.819 --> 00:26:41.240 feeding, like propping a bottle. You're watching 00:26:41.240 --> 00:26:44.420 for delayed introduction of solids past six months. 00:26:44.680 --> 00:26:46.859 And you're watching for colic that doesn't resolve. 00:26:47.180 --> 00:26:49.559 And for the exams, what's the high yield takeaway? 00:26:49.940 --> 00:26:52.859 The timing of solids four to six months and the 00:26:52.859 --> 00:26:55.579 rule for introducing new foods one at a time 00:26:55.579 --> 00:26:57.859 every three to four days. And the memory phrase. 00:26:58.400 --> 00:27:01.779 Milk first, then mash. That was an incredible 00:27:01.779 --> 00:27:04.000 deep dive. We've really covered the A to Z of 00:27:04.000 --> 00:27:06.539 the infant. We connected that triple growth and 00:27:06.539 --> 00:27:09.299 high H vibes physiology to why you have to track 00:27:09.299 --> 00:27:12.039 them so closely. And we linked the developmental 00:27:12.039 --> 00:27:14.880 sequence directly to risk. The cephalocautal 00:27:14.880 --> 00:27:17.140 development means head control happens, then 00:27:17.140 --> 00:27:19.799 sitting happens, and when you add the fine pincer 00:27:19.799 --> 00:27:22.859 grasp, you get this cascade of new safety needs. 00:27:23.180 --> 00:27:25.700 It really is predictable. If you know that two, 00:27:25.700 --> 00:27:29.240 four, six, nine, 12 -month timetable, you know 00:27:29.240 --> 00:27:31.359 the milestones, you know the cognitive leaps 00:27:31.359 --> 00:27:33.680 like object permanence, and you know the anxieties 00:27:33.680 --> 00:27:35.460 that come with them. And it all comes back to 00:27:35.460 --> 00:27:37.440 the maturation of the central nervous system. 00:27:37.539 --> 00:27:40.140 Those primitive reflexes have to go away to unlock 00:27:40.140 --> 00:27:43.259 all of this purposeful voluntary movement. us 00:27:43.259 --> 00:27:45.019 to a final thought for you to take with you. 00:27:45.279 --> 00:27:47.559 We said the Moro reflex should be gone by four 00:27:47.559 --> 00:27:50.180 months. So if you're assessing a nine month old 00:27:50.180 --> 00:27:52.839 and they still have this huge uncontrolled startle 00:27:52.839 --> 00:27:55.319 reflex every time there's a loud noise, what 00:27:55.319 --> 00:27:57.359 does that really imply about their ability to 00:27:57.359 --> 00:27:59.599 master their own body? What complex skill might 00:27:59.599 --> 00:28:01.680 that be getting in the way of? Think about what 00:28:01.680 --> 00:28:04.039 those arms do during a morrow reflex. They fly 00:28:04.039 --> 00:28:07.000 out. How can an infant learn to purposefully 00:28:07.000 --> 00:28:09.940 reach for a toy or transfer an object from hand 00:28:09.940 --> 00:28:12.519 to hand or even bring food to their mouth if 00:28:12.519 --> 00:28:14.880 their arms are being hijacked by this involuntary 00:28:14.880 --> 00:28:18.079 reflex? It's a sign of a major delay in cortical 00:28:18.079 --> 00:28:21.039 maturation. It is. The primitive brain is still 00:28:21.039 --> 00:28:24.130 in charge. And that persistence is getting in 00:28:24.130 --> 00:28:26.410 the way of every voluntary motor skill that's 00:28:26.410 --> 00:28:29.230 supposed to follow. Making that connection from 00:28:29.230 --> 00:28:31.549 a simple reflex to its functional consequence 00:28:31.549 --> 00:28:33.890 is what takes you from being a good student to 00:28:33.890 --> 00:28:36.910 being a great pediatric nurse. Thanks for joining 00:28:36.910 --> 00:28:39.390 us for this deep dive. Study smart, anticipate 00:28:39.390 --> 00:28:41.089 the risk, and we'll catch you on the next one.