NG-408 · NUR 235

🤷 Growth & development, birth to eighteen

Erikson, Piaget, play and fear for all five stages, and the milestones that actually get asked. Almost every stage question is really asking what this age is afraid of — match the intervention to the fear and it answers itself.

🎯 The five stages

One table answers a third of this course.

Match the fear, answer the question Nearly every stage question is really asking what this age is afraid of. INFANT · 0–18 mo Trust vs mistrust · solitary play Fears SEPARATION TODDLER · 1–3 y Autonomy vs shame · parallel play Needs CONTROL — give two choices PRESCHOOL · 3–6 y Initiative vs guilt · associative play Fears BODILY HARM SCHOOL AGE · 6–12 y Industry vs inferiority · cooperative play Fears LOSS OF CONTROL ADOLESCENT · 12–18 y Identity vs role confusion · peer group Fears BEING DIFFERENT
The play type moves solitary → parallel → associative → cooperative. If a question describes two toddlers playing side by side but not together, that is parallel play and it is normal.

👶 What each stage needs from you

  • Infant — keep the parent present, respond promptly. Trust is built by needs being met consistently.
  • Toddler — offer two acceptable choices, never an open question. “Pink cup or blue cup?”, not “Will you take your medicine?”
  • Preschooler — a simple honest explanation, and let them handle the equipment.
  • School age — give tasks and choices, explain the equipment, respect privacy.
  • Adolescent — privacy and confidentiality, involve them in decisions, allow peer visits.

🧠 Piaget, in one line each

  • Sensorimotor (0–2) — learns through senses and movement. Object permanence at 9–10 months.
  • Preoperational (2–7) — magical thinking, animism, egocentrism, centration.
  • Concrete operational (7–11) — conservation, classification, logic about concrete things.
  • Formal operational (11+) — abstract and hypothetical thinking.

Concrete versus formal decides how you teach a procedure, not just what you say.

👶 The first year

Four motor milestones, three growth numbers.

The first year lands on 4 · 6 · 9 · 12 Roll, sit, crawl, walk. Four numbers, in order. 4 months — ROLLS front to back · laughs and coos 6 months — SITS weight DOUBLES · stranger anxiety starts 9 months — CRAWLS pincer grasp · object permanence 9–10 mo 12 months — WALKS weight TRIPLES · 1–3 words · waves bye 2 months is the social smile — the one before the four.
Weight doubles at 6 months and triples at 12. Length is up 50% at one year. Those three are worth memorizing outright.

📈 The growth numbers

  • Up to 10% of birth weight lost in the first 3–4 days
  • Weight doubles by 6 months, triples by 12 months
  • Length up 50% at one year

🧠 Fontanels

  • Posterior closes 6–8 weeks
  • Anterior closes 12–18 months

Bulging at rest = raised ICP. Sunken = dehydration.

😴 Reflexes — when they go

  • Stepping — ~6 wk
  • Tonic neck — 3–4 mo
  • Rooting, palmar, extrusion — ~4 mo
  • Moro — ~6 mo
  • Plantar — 8–9 mo
  • Babinski — ~1 yr

A reflex that persists past its date is the finding, not the reflex itself.

🚨 Safety in year one

  • Back to sleep, every sleep. Firm bare crib, no co-sleeping.
  • Rear-facing car seat, back seat, until at least 2 years
  • No honey before 12 months — infant botulism
  • No cow's milk before 12 months
  • Choking: no nuts, grapes, hot dogs, popcorn

🍼 Feeding, in order

Breast milk or formula only for about 6 months. Both are 20 kcal/oz. Breast milk needs vitamin D and runs out of iron by 4–6 months. Then iron-fortified cereal first, then one new food at a time so an allergy can be spotted.

🧔 Toddler & preschooler

Toddlers need control. Preschoolers need explanation.

🏃 Milestones you should recognize

  • 15 months — walks alone, 3–5 words
  • 2 years — runs, 2-word phrases, ~50% intelligible
  • 3 years — tricycle, 3-word sentences, ~75% intelligible
  • 4 years — hops, dresses self, ~100% intelligible
  • 5 years — skips, ties laces, prints name

Rough rule: words per phrase roughly matches age in years at 2 and 3.

🚨 The leading cause of death in toddlers

Unintentional injury — and every bit of it is preventable teaching.

  • Drowning — never alone near water, including buckets and baths
  • Poisoning — locked cupboards; toddlers explore by mouth
  • Falls — stair gates, window guards
  • Burns — pot handles turned in, water heater turned down

📋 The screening calendar

  • Anemia — 15 and 30 months
  • Lead and autism — 18 and 24 months
  • Vision — from 3 years

Lead above 5 mcg/dL is abnormal; treatment is chelation.

🥛 Feeding a toddler

  • Cow's milk capped at 16–24 oz/day — calcium blocks iron absorption
  • Whole milk until 2, then low-fat
  • Physiologic anorexia — the appetite drop is expected, not pathology
  • Choking foods: hot dogs, whole grapes, raw carrots

⭐ The two answers that keep reappearing

  • Toddler tantrum → ignore the behavior, keep them safe. Attention reinforces it.
  • Toddler resisting care → offer two acceptable choices.

Time-out is one minute per year of age. And preschoolers think illness is punishment — say plainly that it is nobody's fault.

🎒 School age & adolescent

One needs to achieve. The other needs to belong.

🎓 School age — 6 to 12

  • Industry vs inferiority — they need to do things well
  • Cooperative play, team games, collecting
  • Growth slows to about 5 lb and 2 in a year
  • Scoliosis screening in early adolescence, at the growth spurt — forward bend test
  • Fears loss of control and being left out

🧑 Adolescent — 12 to 18

  • Identity vs role confusion — they need to fit in
  • Adolescence delivers 20–25% of adult height
  • Vaccines at 11–12: Tdap (then every 10 y), HPV 2 doses 6–12 mo apart, meningococcal with a booster at 16
  • Commonly deficient in calcium, iron and zinc
  • Fears being different; body image is the adherence problem

📊 Tanner, in one line

Girls start with breast budding, and menarche comes last, roughly two years later. Growth stops 2–2.5 years after menarche.

Boys start with testicular enlargement. Girls start about two years earlier, which is why the growth spurts do not line up.

🚨 Leading cause of adolescent death

Unintentional injury — mainly motor vehicle crashes — then suicide and homicide. Risk-taking peaks because the reward system matures before the judgment system does.

Ask about mood and self-harm directly, and in private. Asking does not plant the idea.

⚠️ Exam traps

  • School age wants facts and control; adolescents want privacy and peers. The wrong intervention for the wrong stage is the classic distractor.
  • Preschoolers read a procedure as punishment — the answer is reassurance, not just distraction.
  • Regression under stress is normal. Normalize it to the parents; do not treat it.
  • Separation anxiety and stranger anxiety overlap in age — read which behavior is described, not the months.
  • Ear assessment flips to up and back after age 3.
Peds