INFANT CARE AND FEEDING

Midwifery

I. Essential Newborn Care (ENC)

 Also known as “Unang Yakap” “First Embrace”
 ENC is a simple cost-effective newborn care intervention that can
improve neonatal as well as maternal care. It is an evidence-based
intervention that emphasizes a core sequence of actions, performed
methodically (step -by-step)
 Is organized so that essential time bound interventions are not
interrupted
 Fills a gap for a package of bundled interventions in a guideline
format
 Legal basis: Administrative Order No. 2009-0025
 Targets MDG: 4
 EINC/Essential Intrapartum and Newborn Care: MDGs 4 and 5

A. Time-bound Interventions
1. Immediate thorough drying (***first 30 seconds) – stimulates
breathing
o ***Dry and provide warmth to the newborn and prevent
hypothermia
o Put on double gloves just before delivery
o Use a clean, dry cloth to thoroughly dry the newborn by wiping
the eyes, face, head, front and back, arms and legs
o ***Do not remove the vernix, instead spread it (this will provide
protection to the newborn from infection/it provides insulation)
o Remove the wet cloth
o Do a quick check of newborn's breathing while drying
o Do not put the newborn on a cold or wet surface
o ***Do not bathe the newborn earlier than 6 hours of life (after 6
hours, then you will provide bathing to the newborn to prevent
infection)
o If the newborn must be separated from his/her mother, put
him/her on a warm surface, in a safe place close to the mother
(to prevent heat loss)
 o ***Put the NB on the mother’s abdomen to promote contraction;
to promote SSC; to promote/provide warmth
2. Early Skin-to-Skin Contact (SSC)
o ***Facilitate bonding between the mother and her newborn
o ***Skin-to-skin contact reduces likelihood of infection and
hypoglycemia (Breastfeeding)
o Place the newborn prone on the mother's abdomen or chest,
skin-to-skin
o Cover the newborn's back with a blanket and head with a
bonnet (insulators to prevent heat loss)
o ***Place the identification band on the ankle (patient identifier)
o Do not separate the newborn from the mother, as long as the
newborn does not exhibit severe chest in-drawing, gasping or
apnea and the mother does not need urgent medical/surgical
stabilization e.g., emergency hysterectomy (removal of the
uterus)
o Do not wipe off vernix if present (to prevent infection)
o Check for multiple births as soon as newborn is securely
positioned on the mother. Palpate the mother's abdomen to
check for a second baby or multiple births. If there is a second
baby (or more), get help. Deliver the second newborn. Manage
like the first baby
3. Properly Timed Cord Clamping (while on skin-to-skin contact; up to 3
minutes post-delivery)
o ***Reduce the incidence of anemia in term newborns and
intraventricular hemorrhage in pre-term newborns
o ***NO milking (milking can cause damage to the NB brain)
o ***Remove the first set of gloves immediately prior to cord
clamping (first set of gloves are already soiled)
o ***Clamp and cut the cord after cord pulsations have stopped
(typically at 1 to 3 minutes). Do not milk the cord towards the
newborn:
 Put ties tightly around the cord at 2 cm and 5 cm from the
newborn's abdomen
 Cut between ties with sterile instrument
 Observe for oozing blood
 o After cord clamping, ensure 10 IU Oxytocin IM is given to the
mother’s deltoid
4. Non-separation of newborn and mother
o ***Facilitate the newborn 's early initiation to breastfeeding and
transfer of colostrum through support and initiation of
breastfeeding (within 90 minutes)
o Leave the newborn on the mother's chest in skin-to-skin contact.
Health workers should not touch the newborn unless there is a
medical indication
o ***Observe the newborn. Advice the mother to start feeding the
newborn once the newborn shows feeding cues (e.g., opening
of mouth, tonguing, licking, rooting)
o Make verbal suggestions to the mother to encourage her
newborn to move toward the breast e.g., nudging.
o Counsel on positioning and attachment. When the newborn is
ready, advise the mother to position and attach her newborn
o Advise the mother not to throw away the colostrum (IgA)
o If the attachment or suckling is not good, try again and reassess
o A small amount of breast milk may be expressed before starting
breastfeeding to soften the nipple area so that it is easier for the
newborn to attach
o Administer erythromycin or tetracycline ointment or 2.5%
povidone-iodine drops to both eyes after the newborn has
located the breast to prevent ophthalmia neonatorum through
proper eye care
o Do not wash away the eye antimicrobial

Time-bound interventions
1. Immediate thorough drying
2. Early skin-to-skin contact
3. Properly timed cord clamping
4. Non-separation of NB and mother

B. Non-Intermediate Interventions (these interventions are usually given

within 6 hours after birth, and should never be made to compete with the
time-bound interventions)
 1. Give Vitamin K (Aquamephyton/Phylloquinone) prophylaxis
o Inject a single dose of Vitamin K IM (if parents decline
intramuscular injections, offer oral vitamin K as a 2nd line)
2. Inject Hepatitis B and BCG vaccinations
o Inject hepatitis B vaccine IM and BCG intradermally
3. Examine the newborn
o Check for birth injuries, malformations or defects
o Weigh the newborn and record
o Look for possible birth injury and/or malformations
o Refer for special treatment and/or evaluation if available
o If the newborn has feeding difficulties because of the
injury/malformation, help the mother to breastfeed. If not
successful, teach her alternative feeding methods
4. ***Cord care
o Wash hands
o Fold diaper below stump. Keep cord stump loosely covered with
clean clothes
o If stump is soiled, mush it with clean water and soap. Dry it
thoroughly with clean cloth (Do not use or apply alcohol; it
causes dryness and irritation)
o Explain to the mother that she should seek care if the umbilicus
is red or draining pus (infection/inflammation)
o Teach the mother to treat local umbilical infection three times a
day (tid)

C. Newborn Resuscitation
1. Start resuscitation if the newborn is not breathing or is gasping after
30 seconds of drying or before 30 seconds of drying if the newborn is
completely floppy and not breathing
2. Clamp and cut the cord immediately
3. Call for help
4. Transfer the newborn to a dry, clean and warm surface. Keep the
newborn wrapped or under a heat source if available
5. Inform the mother that the newborn needs help to breathe
6. Refer to the Department Circular for the step-by-step newborn
resuscitation guideline
D. Additional Care for a small baby or twin - if a newborn is preterm (<37
weeks), 1-2 months early or weighing 1,500 — 2,499 g (or visibly small
where a scale is not available)
1. If the newborn is delivered 2 months earlier or weighs < 1500 g, refer
to a specialized hospital (Tertiary hospitals)
2. For a visibly small newborn or a newborn born month early:
o Teach the mother how to keep the small newborn warm in skin-
to-skin contact via
 Kangaroo Mother Care (KMC). Start kangaroo mother care
when:
 The newborn is able to breathe on its own (no apneic
episodes/difficulty/absence of breathing)
 The newborn is free of life-threatening disease or
malformations
 Reminders:
 The ability to coordinate sucking and swallowing is not
a pre-requisite to KMC. Other methods of feeding can
be used until the newborn can breastfeed
 KMC should as long as possible each day. If the
mother needs to interrupt KMC for a short period, the
father, a relative or friend should take over
o Provide extra blankets for the mother and the newborn, plus
bonnet, mittens and socks for the newborn
o If the mother cannot keep the newborn skin-to-skin because of
complications, wrap the newborn in a clean, dry, warm cloth and
place in a cot. Cover with a blanket
o Use a radiant warmer if the room is not warm or the baby is
small
o Give special support for breastfeeding: Encourage the mother to
breastfeed every 2 – 3 hours
o Weigh the newborn daily
o When the mother and newborn are separated, or if the newborn
is not sucking effectively, use alternative feeding methods
3. Discharge Planning
 o Breastfeeding well and gaining weight adequately for 3
consecutive days
o Body temperature between 36.5 and 37.5 C for 3 consecutive
days
o Mother is able and confident in caring for the newborn

E. Unnecessary Interventions
1. Routine suctioning – Suctioning has no benefit if the amniotic fluid is
clear and especially with newborns who cry or breathe immediately
after birth. Moreover, a dirty bulb can become a source of infection.
Routine suctioning has also been associated with cardiac arrhythmia.
Suctioning is indicated only if the mouth/nose is blocked with
secretions or other materials
2. Early bathing/washing – The WHO recommends bathing at least
after 6 hours of the newborn's life. Bathing the newborn soon after
birth causes a drop in the body's temperature leading to increased
risk of developing infections, coagulation defects and brain
hemorrhage. It also removes the vernix which is protective against
bacteria that cause neonatal sepsis and removes the crawling reflex
3. Foot-printing – Foot-printing has proven to be an inadequate
technique for newborn identification purposes. Better identification
techniques, such as DNA genotyping human leukocyte antigen tests
can serve more this purpose according to the American Academy of
Pediatrics (AAP) and the American College of Obstetricians and
Gynecologists (ACOG)
4. Giving sugar water, formula or other pre-lacteals and the use of
bottles or pacifiers – Delaying initiation to breastfeeding has been
linked to a 2.6-fold increase in the chances of newborn deaths due to
infection. If the sugar water, formula or pre-lacteals are introduced
using a bottle, the newborn may develop a learned preference for the
bottle leading to nipple confusion and inefficient suckling which can
further lead to failure in breastfeeding. A pacifier likewise contributes
to nipple confusion especially if these are used before the newborn is
offered the mother's breast. This undermines the chances of
successful breastfeeding by contributing to a vicious cycle of poor
attachment, sore nipples and lactational insufficiency
***EXCLUSIVE BREASTFEEDING = 6 months
***EXTENDED BREASTFEEDING = 6 months up to 2 years and beyond

5. Application of alcohol, medicine and other substances on the cord

stump and bandaging the cord stump or abdomen – The umbilical
stump is an entry point for systemic infections in the newborn. The
devitalized tissue of the cord stump can be an excellent medium for
bacterial growth, especially if the stump is kept moist and unclean
substances are applied to it. Cleaning with alcohol and bandaging
delays healing and falling off of the stump. The alcohol keeps the
stump moist while bandaging prevents aeration which facilitates the
drying process

F. Discharge Instructions
1. Advise the mother to return or go to the hospital immediately if:
o Jaundice of the soles or any of the following are present
(pathologic jaundice: first 24 hours; physiologic jaundice: 2 days
and more)
o Difficulty of feeding
o Convulsions
o Movement only when stimulated
o Fast or slow or difficult breathing (e.g., severe chest in-drawing)
o Temperature 37.5 C or <35.5 C
2. Advise the mother to bring her newborn to the health facility for
routine check-up at the following prescribed schedule:
o Postnatal visit 1: at 48 — 72 hours of life
o Postnatal visit 2: at 7 days of life
o 1st postpartum visit: preferably 3-5 days; within 1 week
o Immunization visit 1: at 6 weeks of life
3. Advise additional follow-up visits appropriate to problems in the
following:
o Two days — if with breastfeeding difficulty, Low Birth Weight in
the first week of life, red umbilicus, skin infection, eye infection,
thrush or other problems
o Seven days — if Low Birth Weight discharged more than a week
of age and not gaining weight adequately
 4. Advise for Newborn Screening
Additional Notes:
1. Rooming-in – practice of placing the newborn to the same room with
the mother right after delivery up to discharge to facilitate mother-
newborn bonding
2. Wet Nursing – the feeding of the newborn from another mother’s
breast
3. National and World Breastfeeding awareness month – August
4. RA 11148 – Kalusugan at Nutrisyon ng Mag Nanay Act – first 1000
days of life (first 9 months in the womb up to first 24 months of life)
5. RA 10028 – Expanded Breastfeeding Promotion Act
6. RA 7600 – Breastfeeding and Rooming-in Act
7. ***Provisions Kangaroo Mother Care
o Continuous skin to skin contact
o Exclusive breastfeeding
o Early discharge from the hospital
o Close follow up at the health facility

II. Initiation of Breathing

1. Mechanical – compression of the fetal chest on the birth canal= chest
wall recoil leading to passive inspiration
2. Chemical – Increased in peripheral CO2 and decrease in peripheral
O2 and pH
3. Thermal – a change in the temperature (environment)
4. Sensory – tactile (touch), auditory and visual stimuli
***Amniotic fluid within the respiratory tract is absorbed by pulmonary
capillaries

III. Establishing Respiration

Interventions
1. Drying
2. Crying
3. Positioning – skin to skin contact, prone position
4. Suctioning – suction mouth before the nose to prevent aspiration
because NB is an obligatory nasal breather. Suction less than 5
seconds for Pre-Term, and 5-10sec for term
IV. Thermoregulation (Non-shivering thermogenesis)
NO shivering in NB. Heat production is through Brown fat metabolism.
Hypothermia (<36.5-degree Celsius leads to ketone production from
brown fat metabolism leading to acidosis
1. Mechanisms of Heat Loss
o Evaporation – fluid to gas
o Conduction – direct contact
o Convection – air currents
o Radiation – indirect contact (solid)

Complications of Cold Stress

1. Acidosis (burning of brown fats: ketones)
2. Respiratory distress
3. Hypoglycemia (<30mg/dL in the first 24 hours of life)
***Is Oxygenation a routine NB care? Answer: NO. Too much Oxygen
toxicity leads to neonatal blindness (retrolental fibroplasia)

V. Initiating Breastfeeding
3 Es of Breastfeeding
1. Early – immediately (NB placed on the mother’s abdomen)
2. Exclusive – on the first 6 months of life
3. Extended – up to 2 years and beyond

Breast milk
1. Colostrum – first milk, IgA, laxative effect, thin, yellowish, first perfect
food for the NB
2. Transitional milk – milk after colostrum
3. Foremilk – thin, low in calories, produce on the first 10 minutes
breastfeeding
4. Hind milk – thick, high in calories, high fat, produced after 10 minutes
5. Mature milk – containing 10 percent of solids, white with a tinge of
blue
***The best schedule for breastfeeding is – per demand
***Care of the Breasts= nursing pads, no soap, seek care if temp is >38
degree Celsius (mastitis/infection)
***Mastitis and breast engorgements are not contraindications for
breastfeeding
***Lactogenesis – delivery of placenta---decreased progesterone----
Anterior Pituitary Gland---Prolactin----milk production
***Let down reflex – suck the nipples---Posterior Pituitary Gland---
Oxytocin release--- contract the acini cells of the breast--- milk ejection
***LAM – Lactation Amenorrhea Method- no menstruation for first 6
months (prolactin inhibits ovulation)
***Burp the baby= middle and at the end of feeding
***Capacity of infant’s stomach – Age in months + 2 ounces (1 ounce = 30
mL)

Breastfeeding Techniques:
1. Cradle Hold
o It is a natural and most comfortable position for older babies
who can handle their head better
 Sit comfortably with your baby at the level of your heart
 Cradle your little one in your arm with her tummy against
yours and head resting in your elbow bend. Her ear,
shoulders and hip should follow a straight line
 Place your baby’s lower arm under your breast or your
underarm with her mouth near to your breast.
 Using your free hand to support your breast
 Rest your thumb above the areola and the rest of the
fingers beneath the breast
 Now gently fondle your nipple on her lower lip. In response
to the rooting reflex, her mouth opens wide that takes some
time
 Pull her quickly onto the breast and let her latch-on
 Another variation, the laid-back breastfeeding, the mother
rests in a reclined position with tummy to tummy contact
with the baby where her instincts work to get on the breast.
It is a learning process that takes time for the baby to latch-
on
2. Cross-cradle Hold
o This is the common breastfeeding position that is also known as
crossover hold. It offers a great support to the baby and the
mother will have complete control over her baby with just one
hand
  Sit comfortably with your baby at the level of your heart
 Cradle your little one in your arm with her tummy against
yours and your hand at her head base and neck. Her ear,
shoulders and hip should follow a straight line
 Place your baby’s lower arm out of the way with her mouth
near to your breast. Here you will use opposite arms from
the cradle hold position
 Use your free hand to support your breast
 Rest your thumb above the areola and the rest of the
fingers beneath the breast
 Now gently fondle your nipple on her lower lip. In response
to the rooting reflex, her mouth opens wide that takes some
time
 Pull her quickly onto the breast and let her latch-on. Do not
lean over your baby, instead pull her near you
 This position works well when you:
 Nurse a newborn
 Are learning how to position an infant correctly
3. Football Hold
o The football hold is ideal for a mother whose breasts are very
large or who had a C-section. It is also a perfect position for
premature babies or tiny babies as it gives excellent control for
mother over the baby
 Place your baby so that her legs and body are beneath
your arm and your hand at the base of the head and neck
 Place your palm below the breast and let your little one
latch-on by pulling her in close. Hold your baby’s head with
her chin and nose touching your breast.
 When the baby latches on, the mother should make sure
that her shoulders are in a relaxed state.
 This position works well when:
 You have undergone a C-section and want to hold
your baby against the incision of the abdomen
 Your breasts are large
 You want to check in your baby latch-on
 Your little one is restless and fussy
 You have inverted nipples
4. Football Hold for Twin babies
o If you are a mother of twin babies, you might want to feed them
separately or simultaneously. If you wish to feed them
simultaneously, you could try the clutch or ‘football hold’ to allow
each infant to latch onto each breast
 With one baby in each of your arms, hold them while
partially bending your elbow
 You can also place your babies on a pillow each
 Support their neck with your palm, let them incline towards
your body
 Let your babies latch on and suckle

 This method is a good choice when:

 You have undergone a C-section
 Your breasts are large
 You have a tiny baby
 You have a forceful milk ejection reflex
5. Side-lying
o The side-lying position is best when the mother needs some rest
while nursing her baby. It is a bit tricky, but once both the
mother and her baby get hang of it, it will become the most
favorable position. It is best recommended for those who have
undergone a C-section
 Position yourself and your infant towards side tummy to
tummy.
 Bend your upper leg and position your upper knee with
pillows.
 Lift your breast upward by placing fingers below and then
take your baby close to latch-on.
 This position is a good choice when:
 You need to lie flat after a C-section
 You are facing discomfort while sitting due to
hemorrhoid pain
 You want to take a rest.
Latching On:
 If your newborn latches on to your nipple but not the areola,
problems can occur like sore nipples and poor milk supply. In such a
case, you have to repeat some steps for your baby to latch-on
properly:
o Sit with your tummy facing against her tummy
o Ensure that your baby’s ear, shoulder and hip lie straight and
nose is on the same level as nipple
o Touch nipple to your little one’s lips
o Bring her close to your chest
o When her mouth opens wide, bring her quickly so that she
latches-on
 Here is what you need to look for after your baby latches-on:
o Chin touches your breast
o Tongue is seen when the lower lip is pulled
o Lips should be outward the breast
o The sucking motion will be along the jaw
o The ears, shoulder and hip will lie in a straight line
o You should feel a rhythmic tug on your breast
o Ears wiggle
o Cheeks are round (puffy)
o You will not hear smacking or clicking noises
o You will hear swallowing
o While your baby takes off breastfeeding, your nipples are not
flattened
o Your baby ends the feeding with great satisfaction that are
shown by signs like – looks relaxed, falls of the breasts with
open hands and immediately falls asleep
Tips for Every Breastfeeding Technique:
1. Support Your Body: Position of comfort
o Use a comfortable chair that has armrests and take pillows for
extra support to your arms and back
o Keep a footstool or coffee table so that you rest your feet and do
not bend over much. A pillow or a folded blanket on your lap
also keep you comfortable
o Whatever may be the nursing position, you should make sure
you bring your baby near to your breast
2. Support Your Breast:
o Breasts turn heavier and larger when lactating. You should use
your hand to support them using a C-hold (4 fingers below the
breast and thumb above) or a V-hold (between index and middle
finger)
3. Support Your Baby:
o Use your hand and arm along with folded blanket or pillows to
offer a support to your baby’s head, neck, back and hips
o You can wrap her in a blanket or hold in your arms for making
her feel comfortable
4. Alternative Feeding:
o Experiment and find the best position that you and your baby
feel comfortable
o Regularly alternate the breast holds since continuous hold can
put pressure and can cause sore nipples
o Alternating the breast holds will also boost milk production
5. Relax Before Nursing:
o Close your eyes, take a few deep breaths and stay calm, also
keep water, juice or a glass of milk while you nurse since you
may feel dehydrated
6. Time to Stop Feeding:
o If you feel there is need to stop the feed for any reason, slowly
insert your finger near the corner of your baby’s mouth. A gentle
pop will break the feed and can pull off your little one
VI. Determining the APGAR SCORE
 ***at 1 minute= to determine the need for resuscitation
 ***at 5 minutes = to determine adjustment to the environment
SIGNS 0 1 2
Acrocyanosis
–
Pink body,
Blue
extremities
A-ppearance= color due to
Pale Totally pink
Least important sluggish
peripheral
circulation,
Normal for
1st 24-48
hours
P- ulse = Heart rate
Less than
Most important APGAR Absent >100
100
Score
G-rimace= reflex No response Grimace Vigorous cry
A-ctivity= muscle tone Limp Some flexion Full flexion
R-espiratory effort Absent Slow and Loud cry
 irregular
Scoring:
 8-10= routine NB care
 4-7= needs stimulation/ need special care
 0-3= immediate resuscitation

VII. Administering Medications – delay in one hour. After the first full
breastfeeding is completed
 Vitamin K= to prevent neonatal bleeding because GIT is sterile
o (0.5 to 1mg) site: vastus lateralis (anterolateral aspect of the
thigh). Alternate site: rectus femoris (medial thigh)
 Prophylactic Eye Ointment (eye to eye contact first before
administration)
o Erythromycin/tetracycline ointment from inner to outer canthus
of the eyes
o To prevent ophthalmia neonatorum
o To prevent gonorrheal conjunctivitis (Neisseria gonorrhea,
Chlamydia trachomatis; Treponema pallidum)

IMMUNIZATION:

IMMUNITY

NATURAL
ARTIFICIAL
(Protection is developed within
(Protection is given from the outside)
the body)
PASSIVE ACTIVE (long-
PASSIVE ACTIVE
(short-term) term)
(Antibody) (Antigen)
(Antibody) (Antigen)
Maternal Life-long Anti-serum, antitoxin Vaccines,
transfer from protection from agents, toxoids (EPI
the mother to the disease immunoglobulin vaccines)
the baby itself (the (TAT,TAS,TIg, ERIg,
(breastfeeding: patient HRIg)
IgA and developed
 placental immunity from
transfer: IgG) a disease)

EXPANDED PROGRAM ON IMMUNIZATION (EPI)

Goal: To reduce morbidity and mortality related to childhood
immunizable diseases
Legal Bases:
 PD 996: Compulsory Immunization Law
 RA 7846: Hepatitis B Vaccination
 PP 1066: Tetanus Elimination
 PP 773: Knock-out Polio
 RA 10152: Mandatory Infants and Children Health Immunization
Act

Schedule and Doses:

SCHEDULE VACCINES

At birth BCG*, HBV0

At 6 weeks Penta-Hib1, OPV1, RTV1, PCV1**

At 10 weeks Penta-Hib2, OPV2, RTV2, PCV2

 At 14 weeks Penta-Hib3, OPV3, RTV3, PCV3

At 9 months Measles Conjugated Vaccine1*** Anti-

Measles Vaccine

At 12 months MCV2****

At 18 months Diphtheria, Pertussis, Tetanus

TAKE NOTE:
*Infants who are HIV positive, suspect or unknown HIV status with
symptoms consistent with HIV should not be vaccinated with BCG
(immunocompromised)

**HIV-positive infants and pre-term neonates who have received 3

primary doses of Pneumococcal Conjugated Vaccines before 12 months
of age may benefit from a booster dose in the second year of life

***MCV1 refers to monovalent measles (rubeola only) and is 85%

effective if administered at the age of 9 months

****MCV2 refers to combination of Measles, Mumps and Rubella (MMR)

and is 95% effective if administered at the age of 12-15 months. Second
dose of measles vaccine may be given at any opportunistic moment (if
the child is at risk or lives in risk area) during periodic supplementary
immunization activities as early as one month following the first dose.

 Dosage, Route and Site:

VACCINES DOSAGE ROUTE SITE

Bacillus Calmette- Right Deltoid

 Guerin (BCG) - 0.05 ml ID
PTB

Hepatitis B Vaccine 0.5 ml IM Vastus

(HBV) lateralis

Pentavalent Vastus
Vaccine (Penta- 0.5 ml IM lateralis
Hib) *

Oral Polio Vaccine 2-3 gtts PO Mouth

(OPV)

Rotavirus Vaccine Prepacked*** PO Mouth

(RTV)**
- diarrhea

Pneumococcal
Conjugate Vaccine 0.5 ml IM Vastus
(PCV) lateralis

Measles Containing Deltoid or

Vaccine 0.5 ml SQ upper outer
(MCV/AMV) portion of the
arm
 Diphtheria Vastus
Pertussis Tetanus 0.5 ml IM lateralis****
(DPT)

TAKE NOTE:
*Penta-hib composition includes the combination of 5 vaccines such
as Hepatitis B, Diphtheria, Pertussis, Tetanus and Haemophilus
Influenza Type B (for meningitis/inlfuenza)

**RTV is for rotavirus-related gastroenteritis

***RTV dosage is prepacked and may vary according to type of drug:

Rotarix is prepacked at 1.0 ml while Rotateq is prepacked at 2.0 ml.

****DPT at 18 months may only be ad mistered via gluteus maximus if

the child is able to walk already

 Principles:
 It is safe and immunologically effective to administer all EPI
vaccines on the same day at different sites of the body
 Measles Vaccine should be given as soon as the child is 9
months old. If the child is living in an endemic area, give the
vaccine as early as 6 months.
 Vaccination schedule should not be restarted
 Giving doses less than the recommended interval may lessen
the antibody response
 No extra doses must be given to children/mother who missed a
dose of DPT/ Hepa-B/ OPV/ TT
 Strictly follow the principle of never, ever reconstituting the
freeze-dried vaccines other than the diluents supplied with them
 One Syringe, One Needle Per Child during vaccination

 False Contraindications:
 Malnutrition
 Low Grade Fever
 Mild Respiratory Infections like cough and cold
  Simple Diarrhea
 Simple Vomiting

 Absolute Contraindications:
 DPT 2 or DPT3 to a child who has had convulsions or shock
within 3 days the previous dose.
 Patients with neurologic disease should not be given vaccines
containing whole cell pertussis
 Live vaccines like BCG vaccine must not be given to individuals who
are immunosuppressed due to a malignant disease

VIII. Newborn Screening

 RA 9288 or the Newborn Screening Act of 2004 and DOH AO No.
2014-0045 or the Guidelines on the Implementation of the Expanded
Newborn Screening Program
 Newborn screening (NBS) is an essential public health strategy that
enables the early detection and management of several congenital
disorders, which if left untreated, may lead to mental retardation
and/or death. Early diagnosis and initiation of treatment, along with
appropriate long-term care help ensure normal growth and
development of the affected individual. It has been an integral part of
routine newborn care in most developed countries for five decades,
either as a health directive or mandated by law. In the Philippines, it
is a service available since 1996
 PROGRAM COMPONENTS
o Actual screening: It involves all activities, resources and
mechanisms related to the actual screening of newborn babies
o Follow-up and recall of patients who are positive for any of the 6
disorders included in the newborn screening panel and 28
disorders for expanded newborn screening or of patients with
rejected sample
o Diagnosis or confirmation of cases on patients with positive
results in the screening
o Management/treatment and monitoring of babies confirmed to
have the disorder
Screening Procedure
1. Blood Test – A blood test, also called a heel stick, checks for rare but
serious health problems in newborns. The health professional will
prick the baby’s heel to collect a blood sample on a special filter
paper, then send this to the laboratory for analysis. This is often read
by the time the newborn is around five to seven days old.
2. Hearing Test – There are two different tests used to determine if
there are hearing issues on the newborn. Both processes are quick,
safe, and comfortable, and are often done while the baby is sleeping.
o Auditory Brain Stem Response (ABR) Test – This is used to
assess the auditory brain stem and the brain’s response to
sound. Like the OAE test, a miniature earphone is inserted in
the ear to play sounds. If the newborn’s brain does not respond
to the sounds consistently, it may indicate a hearing problem
o Otoacoustic Emissions (OAE) Test – This test helps diagnose if
certain parts of the infant’s ear respond to sound. A tiny
earphone and a microphone are carefully inserted in the ear,
and sounds are played. If there is no echo reflected in the ear
canal (measured by the microphone), it can imply hearing loss
3. Pulse Oximetry Test – This non-invasive test measures how much
oxygen is in an infant’s blood. Babies with heart issues may show
low blood oxygen levels. A pulse oximeter machine is used for the
test, which utilizes a harmless sensor placed on the baby’s skin. The
pulse oximetry test can also determine if an infant has Critical
Congenital Heart Disease (CCHD)
Common Screening Tests for Newborns
 Early diagnosis, treatment, and management are the primary
newborn screening benefits. If newborns are not screened early on,
they may suffer tragic consequences, including brain damage,
developmental and physiological delays, breathing problems, and
even death. Below are the common screening tests for newborns,
including some of the health conditions that they can detect:
1. Metabolic issues: Newborns with organic acid metabolism disorders
find it hard to digest food correctly. Failure to get babies screened for
this may cause developmental delay, breathing problems, and
 neurological damage. Some of the common organic acids that build
up in their body include:
o Propionic acidemia (PROP) – is an inherited disorder in which
the body is unable to process certain parts of proteins and lipids
(fats) properly. It is classified as an organic acid disorder, which
is a condition that leads to an abnormal buildup of particular
acids known as organic acids
o Methylmalonic acidemia – is a disorder in which the body cannot
break down certain proteins and fats. The result is a buildup of a
substance called methylmalonic acid in the blood. This condition
is passed down through families. It is one of several conditions
called an "inborn error of metabolism."
o 3-Methylcrotnyl CoA carboxylase deficiency – 3-methylcrotonyl-
CoA carboxylase deficiency (3-MCC) is an inherited condition in
which the body is unable to break down certain proteins
properly. 3-MCC is considered an organic acid condition
because it can lead to harmful amounts of organic acids and
toxins in the body
o Trifunctional protein deficiency (TFP) – Trifunctional protein
deficiency (TFP) is a condition in which the body is unable to
break down certain fats. It is considered a fatty acid oxidation
condition because people affected by TFP are unable to change
some of the fats they eat into energy the body needs to function.
Instead, too many unused fatty acids build up in the body
2. Hormone issues: These pertain to the glands that produce
hormones. Disorders occur when the glands either make too much or
not enough hormones. These issues can cause growth and
developmental problems if not detected and treated within two (2)
weeks of birth. Endocrine issues that may be detected by a newborn
screening include:
o Congenital hypothyroidism – Congenital hypothyroidism,
previously known as cretinism, is a severe deficiency of thyroid
hormone in newborns. It causes impaired neurological function,
stunted growth, and physical deformities
o Congenital adrenal hyperplasia – is a group of rare inherited
autosomal recessive disorders characterized by a deficiency of
 one of the enzymes needed to make specific hormones. CAH
effects the adrenal glands located at the top of each kidney
3. Hemoglobin issues: These disorders affect the red blood cells
responsible for carrying oxygen to the entire body. Some of the
hemoglobin-related issues screened are:
o Sickle cell disease – Sickle cell anemia is an inherited red blood
cell disorder in which there aren't enough healthy red blood cells
to carry oxygen throughout your body. Normally, the flexible,
round red blood cells move easily through blood vessels. In
sickle cell anemia, the red blood is shaped like sickles or
crescent moons
o Hemoglobin SC disease – Hemoglobin SC disease, is a type of
sickle cell disease, which means it affects the shape of the red
blood cells. Red blood cells contain a protein called hemoglobin,
which is responsible for carrying blood throughout the body
o Beta Thalassemia – Beta thalassemia is a blood disorder that
reduces the production of hemoglobin. Hemoglobin is the iron-
containing protein in red blood cells that carries oxygen to cells
throughout the body. In people with beta thalassemia, low levels
of hemoglobin lead to a lack of oxygen in many parts of the
body
4. Other issues: Newborn screening can also detect rare but serious
medical conditions, such as the following:
o Cystic fibrosis – Cystic fibrosis is a hereditary disease that
affects the lungs and digestive system. The body produces thick
and sticky mucus that can clog the lungs and obstruct the
pancreas. Cystic fibrosis (CF) can be life-threatening, and
people with the condition tend to have a shorter-than-normal life
span
o Pompe disease – Pompe disease is a rare genetic disease
characterized by the abnormal buildup of a sugar molecule
called glycogen inside cells. This buildup impairs the working of
different organs and tissues, especially the heart, respiratory,
and skeletal muscles.
o Spinal muscle atrophy (SMA) – Spinal muscular atrophy (SMA)
is a genetic disease affecting the central nervous system,
peripheral nervous system, and voluntary muscle movement
 (skeletal muscle). Most of the nerve cells that control muscles
are located in the spinal cord, which accounts for the word
spinal in the name of the disease
o Galactosemia – Galactosemia, which means “galactose in the
blood,” refers to a group of inherited disorders that impair the
body's ability to process and produce energy from a sugar
called galactose. When people with galactosemia ingest foods
or liquids containing galactose, undigested sugars build up in
the blood
o Phenylketonuria – Phenylketonuria (commonly known as PKU)
is an inherited disorder that increases the levels of a substance
called phenylalanine in the blood. Phenylalanine is a building
block of proteins (an amino acid) that is obtained through the
diet. It is found in all proteins and in some artificial sweeteners
o G6PD – G6PD deficiency is an inherited condition. It is when the
body doesn't have enough of an enzyme called G6PD (glucose-
6-phosphate dehydrogenase). This enzyme helps red blood
cells work correctly. A lack of this enzyme can cause hemolytic
anemia. This is when the red blood cells break down faster than
they are made

IX. Vital Signs

 Respiration – 30-60cpm, irregular, abdominal, by the end of infancy=
20-30cpm
 Heart Rate – 120-160bpm, 180bpm (crying), 100-120bpm (sleeping).
End of infancy – 100-120bpm
 Temperature – 36.6 to 37.7 degree Celsius (per axilla)
 BP – 60-80- systolic, 40-60 diastolic

X. General Measurements
birth weight = 2.5kg -3.5/4 kg birth length= 47.5cm - 52cm
average is 50
birth weight x 2 = 6 mos. birth length + 50%= 1year old
birth weight x 3 =1 yr. old birth length x 2 = 4 years
birth weight x 4 = 2 years old birth length x 3 = 13 years old
***physiologic weight loss = a loss of 5-10 percent body weight on the first
week of life due to loss of meconium
***head circumference = 33 – 35 (cone head due to molding reduces
HC .5 to 1cm)
***chest circumference =31 – 33
***abdominal circumference =31 – 33

XI. DENTAL AGE

 ***Sign of Teething – resistance to chewing: give cold teethers
5-6 months 2 Lower central incisors
7-8 months 2 upper central incisors
9-10 months 2 upper laterals
11- 12 months 2 lower laterals
1-year-old 4 pairs
2 and a half years’ Complete primary/milk/deciduous teeth
old Eruption of first permanent teeth
6 years’ old Eruption of remaining teeth except the third molars
10-11 years’ old Eruption of the 3rd permanent molars
17-22 years old
***When is the best time to visit the Dentist? = as early as 6 months/at 2
½ years old

XII. Food Introduction

 Introduce one food at a time with an interval of 4-7 days
 Age in months
o 5-6 = cereals
o 7 mos = veggies
o 8 mos = fruits
o 9 mos = meat
o 10 mos = egg (egg yolk muna bago white)
 Infants have difficulty digesting fats until one year. Do not add butter
 Whole milk should not be given during the first year
 Skim milk should not be given until 2 years old

XIII. Characteristics of Normal Newborn

1. HEAD
 Round and symmetrical
 fontanels- soft, flat, patent
 Crying = fontanels is slightly bulging = Normal
 Sleeping = and fontanels are bulging = abnormal, Increased ICP
 Depressed fontanels = dehydration
o Posterior fontanel (lambda)- triangle, closes at 2-3 months
(smaller)
o Anterior fontanel (bregma)- diamond, closes at 12-18 months
(bigger)

CAPUT SUCCEDANEUM – CEPHALHEMATOMA – firm to touch

soft
Scalp edema Collection of blood
Present at birth Present 12-24 hours after delivery
Disappears in few days Reabsorbs in few weeks
Bilateral Unilateral
Crosses suture lines Doesn’t cross suture lines
Due to pressure of soft pelvis Due to pressure of hard pelvis,
forceps

2. FACE
 EYES real color at 3 mos, strabismus = due to poor neuromuscular
control, should be straight by 3 months
 CRYING is tearless = due to poor lacrimal structures (2 months= cry
with tears)
 VISION can see 8-10 inches
 SUBCONJUCTIVAL HEMORRHAGE (red spot in the sclera) normal,
reabsorbed in 2 weeks
 EARS low set ears – Down Syndrome/Trisomy 21, Normal is= the
top of the ear should be at the level of outer canthus of the eyes
 HEARING can elicit moro reflex (embracing motion)
 NOSE sensitive to breastmilk, sneezing present at birth. Coughing
reflex is present 2-3days after delivery
 MOUTH = lips equal, taste is present at birth. All senses are present
on the first 24 hours of life
 o Epstein pearls is normal, milk curd is normal, Oral thrush
(Candida albicans) is abnormal

3.NECK
 Short, with skin folds, moves freely, non-palpable thyroid

4. CHEST
 Cough reflex is present after 2-3 days, murmurs are abnormal
(acyanotic heart defect). Witch milk is Normal. This is only due to
maternal hormones.

5. ABDOMEN
 Kidneys, liver and spleen are normally palpable
 OMPHALANGIA = cord bleeding (common to babies with hemophilia
– clotting factor disorder)
o FOUL DRAINAGE infections

6. GENITALIA
 MALE GENITALIA
o PHIMOSIS tight foreskin Normal up to 3 years
o EPISPADIAS penile opening at dorsal segment (upper)
o HYPOSPADIAS penile opening at ventral segment (baba)
o CRYPTOCHIDISM – undescended testes= most common to pre
term babies, unilateral is more common

 FEMALE GENITALIA
o Hymen is intact and evident
o Clitoris is enlarged
o PSEUDOMENSTRUATION is normal due to hormones, labia
are edematous

7. BACK
 Flat and straight = NORMAL
 With sac/ dimple/ with tuft of hair = Spina BIFIDA (position the baby
prone) Folic acid deficiency/Vitamin B9
8. BUTTOCKS
 Mongolian spots – disappears before the end of infancy

9. ANUS
 The presence of meconium stool confirms anal patency. Report if
there are no meconium stools in the first 24 hours

10. EXTREMITIES
 TALIPES EQUINOVARUS club foot, more common to boys (bootleg
cast for 6 weeks)
 AMELIA/ POCOMELIA absence of limbs (teratogenic effect of
thalidomides)
 CONGENITAL HIP DYSPLASIAS more on breech, first born,
oligohydramnios. More common on girls, also related to relaxin (frog
leg cast/hip spica cast for 6-9 months or triple diaper)
 Polydactyly – extra fingers or toes
 Syndactyly – webbed
 Adactyly – absence

11. SKIN
 PINKISH = normal
 BLUISH = cyanosis – poor circulation/perfusion
 YELLOWISH jaundice
o Pathologic jaundice = first 24 hours. Most common cause of
pathologic jaundice = erythroblastosis fetalis
o Physiologic jaundice = occurring on 2nd day. Most common
cause is = immature liver
 PALLOR = very unlikely to happen
 REDDISH = due to high hematocrit due to increased RBC
 GREENISH = meconium- stained= chronic fetal hypoxia. Mostly post
term

12. SKIN RASHES/MARKS/SIGNS

 MILIA – white pinpoint papules on the nose, cheeks, chin and
forehead. Disappears after 2 weeks
 LANUGO fine downy hair
  VERNIX CASEOSA whitish and cheesy. For thermoregulation
 MONGOLIAN SPOTS – grayish blue patch over the buttocks.
Common to NB with dark complexion
 NEWBORN RASH – pink or white papule rash. Erythema Toxicum
Neonatorum = harmless. Not infectious
 NEVI – stork bites, red spots on eyelids. Fades in 2 years. Common
to newborn with light complexion
 BRUISING = breech/forceps delivery
 DESQUAMATION dry peeling of the skin – common to post term
babies
 HARLEQUIN SIGN – the lower dependent portion of the body is
darker in shades than the upper independent portion due to sluggish
circulation
 NEVUS FLAMMEUS macular purple rash over the face or the thighs
due to congenital capillary malformation

XIV. Reflexes
1. ROOTING – TURNS the head to direction of stimulus. Disappears in
4 months/6 weeks
2. SUCKING – anything that touches her lips is sucked. Disappears in 6
months
3. SWALLOWING – anything that touches the posterior tongue
4. EXTRUSION/SPITTING UP – anything that touches the anterior
tongue. FADES IN 3-4 MONTHS
5. MORO/STARTLE – “DROP METHOD” “hearing method” seen as
embracing motion of the arms, abduction (SPREAD) followed by
adduction (TOWARD) of the arms and legs spread away, disappear
by end of 4 months, stimulates the action of someone trying to ward
off an attacker the covering up to protect self, most significant index
of CNS
6. BABINSKI – fanning of toes when the sole is stroked from the heels
upward due to immaturity of the Nervous System; Most acute on the
1st month and gradually disappears until 12 months
7. TONIC NECK/FENCING – when on supine, infant turns his head to
one side and arms and leg on the side to which the head turns
extend and opposite arm and leg flex. Disappears on 3rd to 4th
MONTH
 8. DARWINIAN – demonstration of a quick few steps when the newborn
is held in a vertical position and feet touch a hard surface. Disappear
on 3RD MONTH. Other terms are STEP-IN-PLACE, WALKING,
DANCING
9. PALMAR – grasp on examiner’s fingers when palm is stimulated.
DISAPPEARS ON 6 MONTHS
10. PLANTAR – tendency to curl toes inward when the sole of the
foot stimulated. Lessen after 8-9 MONTHS IN PREPARATION FOR
WALKING
11. LANDAU – when held on prone with hand underneath him
supporting his trunk, the body demonstrate some muscle tone and
keeps his head in line with the trunk, NOTE: Sagging into inverted
“U” position indicates poor muscle tone

PROTECTIVE = LIFELONG
•BLINKING – protecting the eyes
•SNEEZING – protecting the nose
•YAWNING to protect cells from depleted oxygen
•GAGGING to prevent aspirations

3 REFLEXES USED AS TESTS OF SPINAL CORD

 MAGNET – if pressure is applied to the soles of the feet of an infant
lying in supine position THE NEWBORN WILL PUSH
 CROSSED EXTENSION – if one leg of newborn lying supine is
extended and the soles of the foot is irritated by rubbing it with sharp
object like thumbnails, HE WILL RAISE THE OTHER LEG, CROSS
IT AND TRY TO PUSH AWAY THE HANDS IRRITATING THE
FIRST LEG.
 TRUNK incurvation / Gallant – when the newborn is in prone position
and is touched along the paravertebral area by a probing finger, he
will FLEX HIS TRUNK AND SWING HIS PELVIS TO THE SIDE

XV. Comparison of Preterm and Post Term Newborn

Preterm Post Term > 42 weeks

Late preterm= 34-36weeks
Moderately preterm= 32-34
 weeks
Very preterm= <32 weeks
Ext Extremely preterm= <25
weeks
Small Dry skin
Large head Long nails
Less rounded features Creases on the palms and soles
More lanugo of the feet
Low body temperature – burning Abundant hair on their head
of brown fats Brown, green, yellow skin
Labored breathing – cold stress Dry and desquamating skin
Lack of reflexes
Complications At risk for:
Heart problems Placental insufficiency
Breathing problems Meconium aspiration
Temperature control problems Macrosomia leading to shoulder
Decreased immune system dystocia and prolonged labor
Hypoglycemia (burning of brown
fats)

When to Call the Health Care Provider

1. DOB/or RR >60cpm
2. Cyanosis
3. Jaundice (first 24 hours) – pathologic jaundice
4. Temperature above 38 degree Celsius or below 36.5
5. Vomiting
6. Refusal of two feedings in a row
7. Diarrhea
8. No bowel movements for more than 24 hours (imperforated anus)
9. No urination for 12 hours (most NB urinate within 24 hours, 2-6x daily
for the first 2 days, 6-8x/day)
10. Signs of infection in the eyes, umbilical cord or circumcision
11. Pustules, blisters or rashes on the skin
12. Difficulty in waking baby
13. Any unusual changes in the infant’s behavior or appearance
14. Oral thrush/moniliasis
 15. Return to hospital immediately: DOB, fever, convulsion, not
feeding at all

XVI. Comparison across Pediatric Ages

AGE GROUP SIGNIFICANT PERSON PLAY

FEAR

INFANCY Mother/Primary Caregiver Solitary play

Stranger anxiety

TODDLERS Parents/SIYA Parallel play

Separation anxiety (protest, despair, denial)

PRE-SCHOOLERS Basic family Associative

Mutilation/Castration

SCHOOLERS Teachers/classmates Competitive

Death/lack of belongingness

ADOLESCENCE Peers Social

Death/loss of control

XVII. Growth and Development Milestones

 Major marker of growth and development
 Determines developmental delays
 Principles:
o Cephalocaudal (head-to-toe)
o Orderly (systematic/step-by-step)
o Regular
o Predictable
o General to specific
o Simple to complex
o Proximodistal (near to far)

1 month
  Complete head lags
 Lifts head for short periods
 Follows moving objects into midline vision
 Smiles indiscriminately
2 months
 Holds head up when in prone
 Social smile, cries with tears, cooing sound
 Closure of posterior fontanel (2-3 months)
 Head lag when pulled to sitting position
 No longer clinches fist tightly
 Follows object past midline
 Recognizes parents
 Holds rattle briefly
 Rolls from side to back
3 months
 Reaches for familiar people or object
 Anticipates feeding
 Starts to drool (naglalaway)
 Hold head erect and steady when held in sitting position
 Can hold head but not chest when prone
 Follows moving objects 180 degrees
4 months
 Head control complete (no head lag)
 Can raise head and chest up when prone
 Turns front to back; needs space to turn
 Rolls from back to side
 Laughs aloud; Babbling sound
5 months
 Turn both ways (roll over) safety Alert: always keep side rails up
 Teething rings, handles rattle well
 Enjoys looking around environment
 Takes objects presented to him
6 months (brightly colored toys= can perceived colors) (weaning age from
Breast to bottle)
 Reaches out in the anticipation of being picked-up
 Sits with support
 Puts feet in mouth in supine position
 Vowel sounds “ah, eh”
 Uses palmar grasp; handles bottle well
 Recognizes strangers
 Smiles at self in the mirror (6-7 months)
7 months
 Sits for short period without support
 Transfer objects from hand to hand (6 – 7 months)
 Likes objects that are good sized for transferring
8 months
 Sits without support
 Sits alone steadily for long periods
 PEAK OF STRANGER ANXIETY
 Plantar reflex disappears (6-8 months)
 BEGINS TO FOLLOW SIMPLE COMMANDS LIKE WAVE BYE-BYE
9 months
 Creeps or crawls; need space for creeping
 NEAT PINCER GRASP REFLEX, probes with forefinger SAFETY
ALERT: can now put small objects in the mouth and aspirates
 Finger feeds
 combine 2 syllables “mama & dada” (9-10 months) Dada- first word
10 months
 Pulls self to stand
 Understand the word no
 Respond to name
 PEEK – A – BOO- an example for object permanence, pat a cake,
since they can clap
11 months
 CRUISING
 stand with assistance
 Walking while holding to his crib’s handle
  One word other than mama and dada
 Head and chest circumference equal (10-12 months)
12 months (weaning age from bottle to CUP) actively producing IgG, IgM.
IgA, IgE and IgD are not plentiful until pre schooler
 STANDS ALONE
 Walk with assistance
 Drink from cup (other books 10 months)
 Cooperates in dressing
 Says two words other than mama and dada
 Pots & pans, pull toys and nursery rhymes
 Imitates actions, comes when called
 Follows one – step command and gesture
 Uses mature pincer grasp, throws objects
 Triples birth weights
 Knows own name
 Vocalize 4-5 words
 4 pairs of primary teeth (incisors)
15 Months
 Plateau stage
 WALKS ALONE
 Puts small pellets into small bottle
 Creep upstairs
 4 – 6 words
 Scribbles voluntarily with pencil, holds spoon well, seat self in a chair
18 Months
 Height of POSSESIVENESS – favorite word MINE – EGOCENTRIC
 Bowel control achieved
 Toilet training 18months to 2 years old= bowel training
 No longer rotates a spoon
 Can run and jump in place
 Walks up and downstairs holding on to a person’s hand or railing,
typically places both feet on one step before advancing
 Names one body part
24 months
 2years old--- 2 1/2 = bladder training
  Turns pages one at a time, removes shoes, pants, etc
 Can open doors by turning door knobs, unscrew lids
 50 – 200 words (2-word sentences), knows 5 body parts
 Walk upstairs alone, still using feet on the same step at same time
 Daytime Bladder Control
30 months
 Makes simple lines or stroke or crosses with pencil
 Can jump down from chair
 Knows full name, holds up finger to show age
 Copy a circle
3 years old
 THRUSTING THREES
 Tooth brushing with little supervision
 Unbutton buttons
 Draws a cross, learns how to share
 Knows full name and sex
 Speaks fluently, 200 – 900 words
 NIGHTIME BLADDER CONTROL achieved
 Rides tricycle
 Copies circle
 With 900-word vocabulary
 Undresses without help
 Gives full name
 Jumps off one step
 Walks backward
 Walks upstairs alternating feet and walk downstairs without
assistance 1 foot at a time
4 years old
 Doubles birth length
 Hops on one foot
 Climbs and jumps well
 Walk downstairs alternating feet
 Skips and hops on one foot
 Throws ball overhead
 Copies square
  Dresses self with assistance
 Laces shoes
 Brushes teeth and bathes self
 Peak of aggressiveness and impatience
 Has a 1500-word vocabulary, commonly stutters (4th-5th month)
 Counts 1 to 5
 With a 20-minute attention span
5 years old
 Runs well
 Jumps rope
 Copies triangle
 Skips and hops on alternate feet
 Balances on one foot
 Throws and catches a ball
 Dresses completely without help
 Eager to please
 Takes increase responsibility for actions
 Names 4 or more colors
 Has 2000–2100-word vocabulary
 Knows name and address
 Counts to 10
 With 30-minute attention span
6 years old
 Starts to ride a bicycle
 Ties knot
 Shows extreme sensitivity to criticism
7 years old
 Rides bicycle well
 Increase self-reliance for basic activities
 Engages in active games
 Joins organizations
 Draws a person with 16 parts
 Develops concept of time
8 years
 EYE DEVELOPMENT GENERALLY COMPLETE
  Movements more graceful
9 -10 years
 Normal 20/20 vision
 Has well developed eye-hand coordination
 Better behaved
 Likes schools
 Enjoys team sports
 Boys and girls’ same size (age 9)
 Enjoys reading books and comics
 Enjoys collecting things
11-12 years
 AWKWARD BECAUSE Of GROWTH spurt
 ATTAINS 90 PERCENT OF FACIAL GROWTH
 Eruption of remaining teeth except wisdom, has all permanent teeth
except final molars
 Helps others, increasingly responsible
 More selective in choosing friends, has best friends, loyal to friends,
enjoys peer activities
 Uses telephone
 Develops beginning interest in the opposite sex, boys tease girls,
girls flirt with boys
 Girls bigger than boys (12 years old)
 Reads romance, mystery and adventurous stories

XVIII. Nutrients, Vitamins, and Minerals

1. “GO”
o Go Foods are the type of food that provide fuel and help us ‘go’
and be active
o Examples of ‘Go’ foods include bread, rice, pasta, cereals and
potato
o These foods give our muscles fuel to run, swim, jump, cycle and
our brain fuel to concentrate
o If we don’t eat enough ‘Go’ foods then we can feel tired and
won’t have enough fuel to get through the day
 o It’s important to include ‘Go’ foods at all meals and especially
breakfast so that our body and brain can get ready for the busy
school day ahead
2. “GROW”
o Grow Foods help our body grow bigger and stronger. ‘Grow’
foods help build our body’s bones, teeth and muscles
o Examples of ‘Grow’ foods include chicken, meat, fish, eggs and
milk, cheese and yoghurt
o All of these foods help to keep us feeling full so that we don’t get
hungry straight away.
o ‘Grow’ foods also help keep our brain bright and focused
o If we don’t eat enough ‘Grow’ foods our bodies won’t have the
right building blocks to make us taller and
Stronger
3. “GLOW”
o Glow Foods are full of vitamins and minerals to keep our skin,
hair and eyes bright and glowing.
o ‘Glow’ foods can keep our immune system strong so that we
can fight bugs and viruses
o Examples of ‘Glow’ foods include all fruits and vegetables
o Brightly colored fruits and vegetables are full of vitamins and
minerals and we need to eat different types every day