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The Normal Infant -- First Year of Life

Victoria L. Franklin, MD

 

Breast feeding, bottle feeding, talking about developmental milestones and immunizations. I like to see the newborn back in two weeks. And the reason I see them back in two weeks are two-fold. One to answer questions that might have cropped up during that time period, and number two is to recheck a weight.

Reviewing nutrition: breast. Children have adequate iron stores for the first four to six months of life. In my practice I like to add a poly-vitamin at two months of age that has iron in it. Now you are going to say why? Because I will forget to switch at four months or six months. It's just a quirk of my practice. Nutritionally these newborns need 120 calories per kilogram per day. Formula has 20 calories per ounce. Breast milk about 17 calories per ounce. This is for them to maintain weight and to grow. Vitamin D and iron supplementation, as we discussed. How about fluoride? How many of you know the fluoride content of the water supplies in your communities? Most of you. If your water supply has greater than 0.6 parts per million of fluoride youíll never need fluoride supplementation. Otherwise this is the direction you are going to need to consider, and thatís particularly true in rural areas where you have some of your families that will be on well water where there is no fluoride supplementation.

Developmentally: blinks to light, quiets to sounds, lifts head and reflexes are present. Moro, tonic neck reflex. Movement should be symmetric.

Nutrition, accident prevention, immunization schedule and certainly in our day and age there is a much more emphasis on the car seat than there has been in the past. Are all of you using hepatitis B vaccine as a routine vaccine? I hear mostly yes. It is now recommended as a routine vaccine by the CDC and the ACIP. There are a lot of different schedules for it, but basically three doses. You can give it at birth, you can give it at one month. You have to have at least one month between the first and the second dose, and two months between the second and third. CDC now recommends testing all pregnant women, immunizing all infants and with three doses. Now one of the other things I like to add her is if you are one who didnít use immunizations five or six years ago - as far as hepatitis B - going back and catching up your seven, eight, nine, ten-year-olds is okay. Still three doses. You start at any point. One month between the first doses. Two months between the second and third and you are back on schedule and I would recommend that you start considering that.

Nutritional supplementation: pretty straightforward. At two months: coos, social smile, regards face and can grasp a rattle in the hand. The second hepatitis B. It is now recommended - and I think on page 18 of the handout Iíve included is a schedule of the 1998 recommendations by the American Academy of Family Practice, the American Academy of Pediatrics and the Advisory Council on Immunization Practices - and for all practical purposes I think youíre going to just have to keep up with this on a year-to-year basis. We now can give the DT absorbed pertussis for all four doses of the DPT.

HIB and polio: One of the major changes that has happened in the last year with immunizations is the polio vaccine. It is now recommended or can be given that all four doses can be given as inactivated polio vaccine. You can give the first two as oral polio and the last two as inactivated or vice-versa, or the four as oral polio. Most pediatricians, most people that are experts in immunization practices are advising to move toward inactivated polio vaccine.

I spend a lot of time with my mothers talking about anticipatory guidance: sleep, future development, future immunization schedule, how to get a hold of me if they have questions or problems. Interestingly enough, although we focus most of our time at these visits on medically related problems, the parental concerns in many studies will show a 70 to 80% predominance of their interest in those visits of dealing with social development, developmental milestones, language development, when they are going to walk and those sort of issues, as opposed to height, weight, head circumference, and the physical exam that we spend a great deal of time looking at. Iím not saying we shouldnít do that but there is a little bit of disconnect oftentimes in what our agenda is and what the parents agenda may be.

Now, I talk with my parents about nutrition a lot. The lot I like to spend is that through the first year of life, because of the calorie density of formula or breast milk, that is the predominant nutritional source for growth. It also has the right fat content for brain development and neurologic development. However, as we all know, our mothers and grandmothers etc. will have an influence on the rest of nutrition. If you look at calorie density per volume all of these fall off. Itís fine. You can add cereal, you can add vegetables, you can add fruits. The parents will do it anyway whether you advise them to do it or not. Up to six months most kids do not have the enzyme system in their gut fully developed to digest complex carbohydrates so much of this is not absorbed nutritionally up to that point anyway. Thereís also an extrusion or protrusion reflex as neurologically we are developing so that food that goes in oftentimes comes right back out because they are not neurologically mature enough to move the food from the front of the mouth to the back of the mouth. My emphasis here is that through that first year of life, formula or breast is the majority of the calorie content. Up to six months of life they need 120 calories per kilogram per day to maintain growth. After six months it drops down to 100 to 105.

At four months: raises to prone, may roll prone to supine, follows an object past 180 degrees, plays with hands, smiles responsively and laughs. At five months of age, five to six months of age, if they have not been able to control their head there is a developmental red flag. Something should go off in your mind that something is not right developmentally, and oftentimes youíll see it at four months. They are reaching at five months and they are transferring objects by six months. Those are red flags. If you do not see that developmentally in the children you are caring, a red flag and you should start being concerned about developmentally related delays. Second hepatitis B, if you have not given it at birth, polio, DPT and HIB. Thereís a lot of immunizations that we have added in.

Pertussis. Seven years ago these were absolute contraindications, now they are minor side effects. There are some major side effects. These are not contraindications but again, when I counsel we talked about these and every time I have parents come back for a follow-up visit, ask them about reactions to immunizations. And document them if they have them. The top two: encephalitis within seven days of immunization or frank anaphylaxis are the only two absolute contraindications to DPT. We should see less of all of these using the absorbed, acellular pertussis. These are not contraindications to giving immunizations: mild, acute illnesses, concurrent antibiotic therapy, recent exposure to an infectious disease, prematurity, history of allergies, family history or convulsions. None of those are contraindications. The biggest reason most of our kids get to the first year of life without having their immunizations on schedule is we missed the opportunities. Some of these are reasons we choose not to give them. These are not contraindications.

We are about six months and we are moving through that first year to get that tree out there on the straight an narrow, but we canít quite see toward our goal. Of course some days I feel like Iím up on top of that mountain. Six months: calorie content decreases a little bit, and again, I emphasize developmental milestones: rolls over, sits with support, transfers objects, bears weight on legs. Birth weight should be doubled by four to six months, should be tripled at one year of age. Again, immunizations.

Nine months of age. How many here still have their children back for a nine-month visit? Looks like about one-third, one fourth. Why do you have them back? Does somebody want to volunteer? Keep an eye on them. Shots? There arenít any shots. Catch-up shots? Okay. Great. I think one of the things is that every one of these visits you are following height, weight, head circumference and you are asking and looking for developmental milestones. I think there is a good reason through that first year of life, even though we are not giving immunizations at that time, to maintain that nine month visit. And I think it is even more critical for first time mothers. Crawls, creeps at nine months. Sits well, pins or grasps. Can say two or three words. Social games. At this point, as far as red flags, if they are not sitting hands-free by eight to nine months, there is some developmental delay. One of the other things - I neglected to mention this before - what is the number one cause of death in kids a year or less in age? Accidents. Whatís the number one cause of accidental death? MVAís. Automobiles. However, burnings, drownings, ingestions, rank right up there. There are 400 kids per month, less than four-years-of-age who die from accidents in the United States. Three or four years ago we had a nine-month-old who was developmentally advanced, cruising around the bathroom. The toilet seat was up, tipped over, fell into the stool - obviously they cannot pull themselves back out - and drowned in the toilet. I have to admit, having five kids, Iím not sure that we always had our toilet seats down when they were at that age either. Pretty hard to do. Itís hard enough to get them to flush the toilet let alone put the seat down. But these are some of the developmental milestones you want to be looking for. And always talk about accident prevention. Car seats. Itís just devastating when one of the kids you are taking care of has this kind of issue.

At twelve months, Iím moving on, they can stop the formula, they can stop breast feeding. Or if they want to they can continue it if they like to. My recommendation at that point is whole milk. Why? We know from recent scientific studies that the brain continues to develop well after the first year of life and into the second year of development. And the brain needs high fat content for it to fully mature. The pediatric cardiologists and the pediatricians who deal with cholesterol fully support this up through two years of life. Then you can switch back to 1%, 2%, skim milk, whatever your nutritional background and education has taught you, but they do need the fat content of whole milk. And again, itís worthwhile spending some time explaining to your parents why that is important. Developmental milestones you should look for at a year. If they are not pulling up by 11 months of age, if they are not walking by 15 months of age - obviously thatís not a year - but those are the things that you can put in your mind and also in your parentís mind. When they are concerned that Johnny or Sue is not walking and their neighbor or cousin has at nine months, that is Ö those others were precocious. Somewhere between 12 and 15 months kids take their first independent steps. If they have not by 15 months be concerned about developmental delays. As far as language development, interestingly enough, kids would not be developmentally delayed language-wise unless they could not form two word sentences by the age of two years, and three word sentences by the age of three to four years. I can tell you, from working with my parents, thatís a hard one to sell to parents who think the kids should be speaking fluent English by two, two-and-a-half years of age. But that is not developmentally an expectation. Two word sentences by two years, three word sentences by three to four years of age.

Hepatitis B, if you havenít given it earlier. At 12 months of age now we can give the HIB, the varicella and the MMR. How many out in the audience are giving the varicella on a routine basis now? Seven? Iím a recent converter this year. I think there is no real reason not to. Looking again through the literature the risk is so low, the coverage is very high and the concern about Ö my concern, why I did not go before, was the concern about the varicella having to leak through it in the adolescent and the young adult years, like MMR. The studies are now out about 15 years and show that there isnít a leak through or another recurrence of varicella. I do know that the transition has gone from nobody giving it, about two years ago, to maybe ten in the audience giving it. I think that youíll find most of us in three to five years will be giving this on a routine basis. Itís one dose if you give it at this point. If you donít give it at this point, it will be two doses if you wait past the age of 13 years. And an MMR at 12 to 15 months.

Fifteen month visit is not one that I include routinely in my practice, but if I have not gotten all the immunizations up to date, or we need to give the last dose of HIB because I didnít give it at 12 months, weíll go ahead and add it in here. Developmentally we talked about those milestones. Walking by 15 months, running by 20 months. Again, giving some anticipatory guidance to our parents is very helpful in the management and care of the newborn. They may know three to five words. They can point to pictures. Functional use of objects and they understand a few phrases like "no", "give me". They may not follow them but they should understand them. Then the fourth dose of DPT at either 15 or 18 months.

Eighteen month developmental guidelines. I have in here "walks" because if they donít walk by 15 months you should have a huge red flag. If they are certainly not walking by 18 months youíve got some significant problems developmentally. Hopefully if you have been following the rest of the developmental milestones youíve picked that up earlier.

Okay, so here we are. The clouds have cleared, weíve got a brisk mountain stream, itís a beautiful day and this young child is well on its way to the early toddler years, with good nutritional parameters. Height, weight and head circumference are where you would like them to be, and remember on that growth curve that you use for height, weight and head circumference, if you have a breast-fed baby, they may be at the lower end of the scale in the 25th percentile, even the 5 or 10th percentile and be normal for breast-fed babies. Those growth charts were built on formula-fed infants. They were also built on Caucasian, African-American infants from this continent, not from other continents. So they may not apply to every ethnic group that youíll be working with.