What you’ll learn to do: describe physical growth and development in infants and toddlers

We’ll begin this section by reviewing the physical development that occurs during infancy, a period that starts at birth and continues until the second birthday. We’ll see how this time involves rapid growth, not only in observable changes like height and weight, but also in brain development.

Next we will explore reflexes. At birth, infants are equipped with a number of reflexes, which are involuntary movements in response to stimulation. We will explore these innate reflexes and then consider how these involuntary reflexes are eventually modified through experiences to become voluntary movements and the basis for motor development as skills emerge that allow an infant to grasp food, roll over, and take the first step.

Third, we will explore the baby’s senses. Every sense functions at birth—newborns use all of their senses to attend to everything and every person. We will explore how infants’ senses develop and how sensory systems like hearing and vision operate, and how infants take in information through their senses and transform it into meaningful information.

Finally, since growth during infancy is so rapid and the consequence of neglect can be severe, we will consider some of the influences on early physical growth, particularly the importance of nutrition.

Physical Growth and Brain Development in Infancy

Overall Physical Growth

The average newborn weighs approximately 7.5 pounds, although a healthy birth weight for a full-term baby is considered to be between 5 pounds, 8 ounces (2,500 grams) and 8 pounds, 13 ounces (4,000 grams).^[1] The average length of a newborn is 19.5 inches, increasing to 29.5 inches by 12 months and 34.4 inches by 2 years old (WHO Multicentre Growth Reference Study Group, 2006).

For the first few days of life, infants typically lose about 5 percent of their body weight as they eliminate waste and get used to feeding. This often goes unnoticed by most parents, but can be cause for concern for those who have a smaller infant. This weight loss is temporary, however, and is followed by a rapid period of growth. By the time an infant is 4 months old, it usually doubles in weight, and by one year has tripled its birth weight. By age 2, the weight has quadrupled. The average length at 12 months (one year old) typically ranges from 28.5-30.5 inches. The average length at 24 months (two years old) is around 33.2-35.4 inches (CDC, 2010).

Monitoring Physical Growth

As mentioned earlier, growth is so rapid in infancy that the consequences of neglect can be severe. For this reason, gains are closely monitored. At each well-baby check-up, a baby’s growth is compared to that baby’s previous numbers. Often, measurements are expressed as a percentile from 0 to 100, which compares each baby to other babies the same age. For example, weight at the 40th percentile means that 40 percent of all babies weigh less, and 60 percent weight more. For any baby, pediatricians and parents can be alerted early just by watching percentile changes. If an average baby moves from the 50th percentile to the 20th, this could be a sign of failure to thrive, which could be caused by various medical conditions or factors in the child’s environment. The earlier the concern is detection, the earlier intervention and support can be provided for the infant and caregiver.

Body Proportions

Another dramatic physical change that takes place in the first several years of life is a change in body proportions. The head initially makes up about 50 percent of a person’s entire length when developing in the womb. At birth, the head makes up about 25 percent of a person’s length (just imagine how big your head would be if the proportions remained the same throughout your life!). In adulthood, the head comprises about 15 percent of a person’s length.^[2] Imagine how difficult it must be to raise one’s head during the first year of life! And indeed, if you have ever seen a 2- to 4-month-old infant lying on their stomach trying to raise the head, you know how much of a challenge this is.

The Brain in the First Two Years

Some of the most dramatic physical change that occurs during this period is in the brain. At birth, the brain is about 25 percent of its adult weight, and this is not true for any other part of the body. By age 2, it is at 75 percent of its adult weight, at 95 percent by age 6, and at 100 percent by age 7 years.

Communication within the central nervous system (CNS), which consists of the brain and spinal cord, begins with nerve cells called neurons. Neurons connect to other neurons via networks of nerve fibers called axons and dendrites. Each neuron typically has a single axon and numerous dendrites which are spread out like branches of a tree (some will say it looks like a hand with fingers). The axon of each neuron reaches toward the dendrites of other neurons at intersections called synapses, which are critical communication links within the brain. Axons and dendrites do not touch, instead, electrical impulses in the axons cause the release of chemicals called neurotransmitters which carry information from the axon of the sending neuron to the dendrites of the receiving neuron.

While most of the brain’s 100 to 200 billion neurons are present at birth, they are not fully mature. Each neural pathway forms thousands of new connections during infancy and toddlerhood. During the next several years, dendrites, or connections between neurons, will undergo a period of transient exuberance or temporary dramatic growth (exuberant because it is so rapid and transient because some of it is temporary). There is a proliferation of these dendrites during the first two years so that by age 2, a single neuron might have thousands of dendrites. After this dramatic increase, the neural pathways that are not used will be eliminated through a process called pruning, thereby making those that are used much stronger. It is thought that pruning causes the brain to function more efficiently, allowing for mastery of more complex skills (Hutchinson, 2011). Transient exuberance occurs during the first few years of life, and pruning continues through childhood and into adolescence in various areas of the brain. This activity is occurring primarily in the cortex or the thin outer covering of the brain involved in voluntary activity and thinking.

The prefrontal cortex, located behind the forehead, continues to grow and mature throughout childhood and experiences an addition growth spurt during adolescence. It is the last part of the brain to mature and will eventually comprise 85 percent of the brain’s weight. Experience will shape which of these connections are maintained and which of these are lost. Ultimately, about 40 percent of these connections will be lost (Webb, Monk, & Nelson, 2001). As the prefrontal cortex matures, the child is increasingly able to regulate or control emotions, to plan activity, to strategize, and have better judgment. Of course, this is not fully accomplished in infancy and toddlerhood but continues throughout childhood and adolescence.

Another major change occurring in the central nervous system is the development of myelin, a coating of fatty tissues around the axon of the neuron. Myelin helps insulate the nerve cell and speed the rate of transmission of impulses from one cell to another. This enhances the building of neural pathways and improves coordination and control of movement and thought processes. The development of myelin continues into adolescence but is most dramatic during the first several years of life.

Motor and Sensory Development

From Reflexes to Voluntary Movements

Every basic motor skill (any movement ability) develops over the first two years of life. The sequence of motor skills first begins with reflexes. Infants are equipped with a number of reflexes, or involuntary movements in response to stimulation, and some are necessary for survival. These include the breathing reflex, or the need to maintain an oxygen supply (this includes hiccups, sneezing, and thrashing reflexes), reflexes that maintain body temperature (crying, shivering, tucking the legs close, and pushing away blankets), the sucking reflex, or automatically sucking on objects that touch their lips, and the rooting reflex, which involves turning toward any object that touches the cheek (which manages feeding, including the search for a nipple). Other reflexes are not necessary for survival, but signify the state of brain and body functions. Some of these include:the babinski reflex (toes fan upward when feet are stroked), the stepping reflex (babies move their legs as if to walk when feet touch a flat surface), the palmar grasp (the infant will tightly grasp any object placed in its palm), and the moro reflex (babies will fling arms out and then bring to chest if they hear a loud noise). These movements occur automatically and are signals that the infant is functioning well neurologically. Within the first several weeks of life, these reflexes are replaced with voluntary movements or motor skills.

Motor development

Motor development occurs in an orderly sequence as infants move from reflexive reactions (e.g., sucking and rooting) to more advanced motor functioning. This development proceeds in a cephalocaudal (from head-down) and proximodistal (from center-out) direction. For instance, babies first learn to hold their heads up, then sit with assistance, then sit unassisted, followed later by crawling, pulling up, cruising, and then walking. As motor skills develop, there are certain developmental milestones that young children should achieve. For each milestone, there is an average age, as well as a range of ages in which the milestone should be reached. An example of a developmental milestone is a baby holding up its head. Babies on average are able to hold up their head at 6 weeks old, and 90% of babies achieve this between 3 weeks and 4 months old. If a baby is not holding up his head by 4 months old, he is showing a delay. On average, most babies sit alone at 7 months old. Sitting involves both coordination and muscle strength, and 90% of babies achieve this milestone between 5 and 9 months old (CDC, 2018). If the child is displaying delays on several milestones, that is a reason for concern, and the parent or caregiver should discuss this with the child’s pediatrician. Some developmental delays can be identified and addressed through early intervention.

Gross Motor Skills

Gross motor skills are voluntary movements that involve the use of large muscle groups and are typically large movements of the arms, legs, head, and torso. These skills begin to develop first. Examples include moving to bring the chin up when lying on the stomach, moving the chest up, rocking back and forth on hands and knees. But it also includes exploring an object with one’s feet as many babies do, as early as 8 weeks of age, if seated in a carrier or other device that frees the hips. This may be easier than reaching for an object with the hands, which requires much more practice (Berk, 2007). And sometimes an infant will try to move toward an object while crawling and surprisingly move backward because of the greater amount of strength in the arms than in the legs!

Fine Motor Skills

Fine motor skills are more exact movements of the hands and fingers and include the ability to reach and grasp an object. These skills focus on the muscles in the fingers, toes, and eyes, and enable coordination of small actions (e.g., grasping a toy, writing with a pencil, and using a spoon). Newborns cannot grasp objects voluntarily but do wave their arms toward objects of interest. At about 4 months of age, the infant is able to reach for an object, first with both arms and within a few weeks, with only one arm. Grasping an object involves the use of the fingers and palm, but no thumbs. Stop reading for a moment and try to grasp an object using the fingers and the palm. How does that feel? How much control do you have over the object? If it is a pen or pencil, are you able to write with it? Can you draw a picture? The answer is, probably not. Use of the thumb comes at about 9 months of age when the infant is able to grasp an object using the forefinger and thumb (the pincer grasp). This ability greatly enhances the ability to control and manipulate an object, and infants take great delight in this newfound ability. They may spend hours picking up small objects from the floor and placing them in containers. By 9 months, an infant can also watch a moving object, reach for it as it approaches, and grab it. This is quite a complicated set of actions if we remember how difficult this would have been just a few months earlier.

Sensory Development

As infants and children grow, their senses play a vital role in encouraging and stimulating the mind and in helping them observe their surroundings. Two terms are important to understand when learning about the senses. The first is sensation, or the interaction of information with the sensory receptors. The second is perception, or the process of interpreting what is sensed. It is possible for someone to sense something without perceiving it. Gradually, infants become more adept at perceiving with their senses, making them more aware of their environment and presenting more affordances or opportunities to interact with objects.

Vision

What can young infants see, hear, and smell? Newborn infants’ sensory abilities are significant, but their senses are not yet fully developed. Many of a newborn’s innate preferences facilitate interaction with caregivers and other humans. The womb is a dark environment void of visual stimulation. Consequently, vision is the most poorly developed sense at birth. Newborns typically cannot see further than 8 to 16 inches away from their faces, have difficulty keeping a moving object within their gaze, and can detect contrast more than color differences. If you have ever seen a newborn struggle to see, you can appreciate the cognitive efforts being made to take in visual stimulation and build those neural pathways between the eye and the brain.

Although vision is their least developed sense, newborns already show a preference for faces. When you glance at a person, where do you look? Chances are you look into their eyes. If so, why? It is probably because there is more information there than in other parts of the face. Newborns do not scan objects this way; rather, they tend to look at the chin or another less detailed part of the face. However, by 2 or 3 months, they will seek more detail when visually exploring an object and begin showing preferences for unusual images over familiar ones, for patterns over solids, faces over patterns, and three-dimensional objects over flat images. Newborns have difficulty distinguishing between colors, but within a few months are able to discrimination between colors as well as adults. Infants can also sense depth as binocular vision develops at about 2 months of age. By 6 months, the infant can perceive depth perception in pictures as well (Sen, Yonas, & Knill, 2001). Infants who have experience crawling and exploring will pay greater attention to visual cues of depth and modify their actions accordingly (Berk, 2007).

Hearing

The infant’s sense of hearing is very keen at birth. If you remember from an earlier module, this ability to hear is evidenced as soon as the 5th month of prenatal development. In fact, an infant can distinguish between very similar sounds as early as one month after birth and can distinguish between a familiar and non-familiar voice even earlier. Babies who are just a few days old prefer human voices, they will listen to voices longer than sounds that do not involve speech (Vouloumanos & Werker, 2004), and they seem to prefer their mother’s voice over a stranger’s voice (Mills & Melhuish, 1974). In an interesting experiment, 3-week-old babies were given pacifiers that played a recording of the infant’s mother’s voice and of a stranger’s voice. When the infants heard their mother’s voice, they sucked more strongly at the pacifier (Mills & Melhuish, 1974). Some of this ability will be lost by 7 or 8 months as a child becomes familiar with the sounds of a particular language and less sensitive to sounds that are part of an unfamiliar language.

Pain and Touch

Immediately after birth, a newborn is sensitive to touch and temperature, and is also sensitive to pain, responding with crying and cardiovascular responses. Newborns who are circumcised (the surgical removal of the foreskin of the penis) without anesthesia experience pain, as demonstrated by increased blood pressure, increased heart rate, decreased oxygen in the blood, and a surge of stress hormones (United States National Library of Medicine, 2016). According to the American Academy of Pediatrics (AAP), there are medical benefits and risks to circumcision. They do not recommend routine circumcision, however, they stated that because of the possible benefits (including prevention from urinary tract infections, penile cancer, and some STDs) parents should have the option to circumcise their sons if they want to (AAP, 2012).^[5]

The sense of touch is acute in infants and is essential to a baby’s growth of physical abilities, language and cognitive skills, and socio-emotional competency. Touch not only impacts short-term development during infancy and early childhood but also has long-term effects, suggesting the power of positive gentle touch from birth. Through touch, infants learn about their world, bond with their caregiver, and communicate their needs and wants. Research emphasizes the great benefits of touch for premature babies, but the presence of such contact has been shown to benefit all children (Stack, D. M. (2010).^[6] In an extreme example, some children in Romania were reared in orphanages in which a single care worker may have had as many as 10 infants to care for at one time. These infants were not often helped or given toys with which to play. As a result, many of them were developmentally delayed (Nelson, Fox, & Zeanah, 2014).^[7] When we discuss emotional and social development later in this module, you will also see the important role that touch plays in helping infants feel safe and protected, which builds trust and secure attachments between the child and their caregiver.

Taste and Smell

Not only are infants sensitive to touch, but newborns can also distinguish between sour, bitter, sweet, and salty flavors and show a preference for sweet flavors. They can distinguish between their mother’s scent and that of others, and prefer the smell of their mothers. A newborn placed on the mother’s chest will inch up to the mother’s breast, as it is a potent source of the maternal odor. Even on the first day of life, infants orient to their mother’s odor and are soothed, when crying, by their mother’s odor (Sullivan et al., 2011).^[8]

Nutrition

Good nutrition in a supportive environment is vital for an infant’s healthy growth and development. Remember, from birth to 1 year, infants triple their weight and increase their height by half, and this growth requires good nutrition. For the first 6 months, babies are fed breast milk or formula. Starting good nutrition practices early can help children develop healthy dietary patterns. Infants need to receive nutrients to fuel their rapid physical growth. Malnutrition during infancy can result in not only physical but also cognitive and social consequences. Without proper nutrition, infants cannot reach their physical potential.

Benefits of Breastfeeding

Breast milk is considered the ideal diet for newborns due to the nutrition makeup of colostrum and subsequent breastmilk production. Colostrum, the milk produced during pregnancy and just after birth, has been described as “liquid gold. Colostrum is packed with nutrients and other important substances that help the infant build up his or her immune system. Most babies will get all the nutrition they need through colostrum during the first few days of life (CDC, 2018).^[9] Breast milk changes by the third to fifth day after birth, becoming much thinner, but containing just the right amount of fat, sugar, water, and proteins to support overall physical and neurological development. It provides a source of iron more easily absorbed in the body than the iron found in dietary supplements, it provides resistance against many diseases, it is more easily digested by infants than formula, and it helps babies make a transition to solid foods more easily than if bottle-fed.

The reason infants need such a high fat content is the process of myelination which requires fat to insulate the neurons. Therefore, there has been some research, including meta-analyses, to show that breastfeeding is connected to advantages with cognitive development (Anderson, Johnstone, & Remley, 1999)^[10]. Low birth weight infants had the greatest benefits from breastfeeding than did normal-weight infants in a meta-analysis that of twenty controlled studies examining the overall impact of breastfeeding (Anderson et al., 1999). This meta-analysis showed that breastfeeding may provide nutrients required for rapid development of the immature brain and be connected to more rapid or better development of neurologic function. The studies also showed that a longer duration of breastfeeding was accompanied by greater differences in cognitive development between breastfed and formula-fed children. Whereas normal-weight infants showed a 2.66-point difference, low-birth-weight infants showed a 5.18-point difference in IQ compared with weight-matched, formula-fed infants (Anderson et al, 1999). These studies suggest that nutrients present in breast milk may have a significant effect on neurologic development in both premature and full-term infants.

For most babies, breast milk is also easier to digest than formula. Formula-fed infants experience more diarrhea and upset stomachs. The absence of antibodies in formula often results in a higher rate of ear infections and respiratory infections. Children who are breastfed have lower rates of childhood leukemia, asthma, obesity, type 1 and 2 diabetes, and a lower risk of SIDS. For all of these reasons, it is recommended that mothers breastfeed their infants until at least 6 months of age and that breast milk be used in the diet throughout the first year (U.S. Department of Health and Human Services, 2004a in Berk, 2007).

Several recent studies have reported that it is not just babies that benefit from breastfeeding. Breastfeeding stimulates contractions in the uterus to help it regain its normal size, and women who breastfeed are more likely to space their pregnancies farther apart. Mothers who breastfeed are at lower risk of developing breast cancer, especially among higher-risk racial and ethnic groups (Islami et al., 2015).^[11] Other studies suggest that women who breastfeed have lower rates of ovarian cancer (Titus-Ernstoff, Rees, Terry, & Cramer, 2010)^[12], and reduced risk for developing Type 2 diabetes (Gunderson, et al., 2015)^[13], and rheumatoid arthritis (Karlson, Mandl, Hankinson, & Grodstein, 2004).^[14]

Most mothers who breastfeed in the United States stop breastfeeding at about 6-8 weeks, often in order to return to work outside the home (United States Department of Health and Human Services (USDHHS), 2011^[15]). Mothers can certainly continue to provide breast milk to their babies by expressing and freezing the milk to be bottle fed at a later time or by being available to their infants at feeding time, but some mothers find that after the initial encouragement they receive in the hospital to breastfeed, the outside world is less supportive of such efforts. Some workplaces support breastfeeding mothers by providing flexible schedules and welcoming infants, but many do not. And the public support of breastfeeding is sometimes lacking. Women in Canada are more likely to breastfeed than are those in the United States, and the Canadian health recommendation is for breastfeeding to continue until 2 years of age. Facilities in public places in Canada such as malls, ferries, and workplaces provide more support and comfort for the breastfeeding mother and child than found in the United States.

In addition to the nutritional and health benefits of breastfeeding, breast milk is free! Anyone who has priced formula recently can appreciate this added incentive to breastfeeding. Prices for a month’s worth of formula can easily range from $130-$200. Prices for a year’s worth of formula and feeding supplies can cost well over $1,500 (USDHHS, 2011).

When Breastfeeding Doesn’t Work

There are occasions where mothers may be unable to breastfeed babies, often for a variety of health, social, and emotional reasons. For example, breastfeeding generally does not work: 

• when the baby is adopted 
• when the biological mother has a transmissible disease such as tuberculosis or HIV
• when the mother is addicted to drugs or taking any medication that may be harmful to the baby (including some types of birth control)
• when the infant was born to (or adopted by) a family with two fathers and the surrogate mother is not available to breastfeed
• when there are attachment issues between mother and baby
• when the mother or the baby is in the Intensive Care Unit (ICU) after the delivery process
• when the baby and mother are attached but the mother does not produce enough breast-milk

One early argument given to promote the practice of breastfeeding (when health issues are not the case) is that it promotes bonding and healthy emotional development for infants. However, this does not seem to be a unique case. Breastfed and bottle-fed infants adjust equally well emotionally (Ferguson & Woodward, 1999). This is good news for mothers who may be unable to breastfeed for a variety of reasons and for fathers who might feel left out as a result.

Introducing Solid Foods

Breast milk or formula is the only food a newborn needs, and the American Academy of Pediatrics recommends exclusive breastfeeding for the first six months after birth. Solid foods can be introduced from around six months onward when babies develop stable sitting and oral feeding skills but should be used only as a supplement to breast milk or formula. By six months, the gastrointestinal tract has matured, solids can be digested more easily, and allergic responses are less likely. The infant is also likely to develop teeth around this time, which aids in chewing solid food. Iron-fortified infant cereal, made of rice, barley, or oatmeal, is typically the first solid introduced due to its high iron content. Cereals can be made of rice, barley, or oatmeal. Generally, salt, sugar, processed meat, juices, and canned foods should be avoided.

Though infants usually start eating solid foods between 4 and 6 months of age, more and more solid foods are consumed by a growing toddler. Pediatricians recommended introducing foods one at a time, and for a few days, in order to identify any potential food allergies. Toddlers may be picky at times, but it remains important to introduce a variety of foods and offer food with essential vitamins and nutrients, including iron, calcium, and vitamin D.

Milk Anemia in the United States

About 9 million children in the United States are malnourished (Children’s Welfare, 1998). More still suffer from milk anemia, a condition in which milk consumption leads to a lack of iron in the diet. The prevalence of iron deficiency anemia in 1- to 3-year-old children seems to be increasing (Kazal, 2002)^[16]. The body gets iron through certain foods. Toddlers who drink too much cow’s milk may also become anemic if they are not eating other healthy foods that have iron. This can be due to the practice of giving toddlers milk as a pacifier when resting, riding, walking, and so on. Appetite declines somewhat during toddlerhood and a small amount of milk (especially with added chocolate syrup) can easily satisfy a child’s appetite for many hours. The calcium in milk interferes with the absorption of iron in the diet as well. There is also a link between iron deficiency anemia and diminished mental, motor, and behavioral development. In the second year of life, iron deficiency can be prevented by the use of a diversified diet that is rich in sources of iron and vitamin C, limiting cow’s milk consumption to less than 24 ounces per day, and providing a daily iron-fortified vitamin. 

Global Considerations and Malnutrition

In the 1960s, formula companies led campaigns in developing countries to encourage mothers to feed their babies on infant formula. Many mothers felt that formula would be superior to breast milk and began using formula. The use of formula can certainly be healthy under conditions in which there is adequate, clean water with which to mix the formula and adequate means to sanitize bottles and nipples. However, in many of these countries, such conditions were not available and babies often were given diluted, contaminated formula which made them become sick with diarrhea and become dehydrated. These conditions continue today and now many hospitals prohibit the distribution of formula samples to new mothers in efforts to get them to rely on breastfeeding. Many of these mothers do not understand the benefits of breastfeeding and have to be encouraged and supported in order to promote this practice.

The World Health Organization (2018) recommends:

• initiation of breastfeeding within one hour of birth
• exclusive breastfeeding for the first six months of life
• introduction of solid foods at six months together with continued breastfeeding up to two years of age or beyond

Children in developing countries and countries experiencing the harsh conditions of war are at risk for two major types of malnutrition. Infantile marasmus refers to starvation due to a lack of calories and protein. Children who do not receive adequate nutrition lose fat and muscle until their bodies can no longer function. Babies who are breastfed are much less at risk of malnutrition than those who are bottle-fed. After weaning, children who have diets deficient in protein may experience kwashiorkor, or the “disease of the displaced child,” often occurring after another child has been born and taken over breastfeeding. This results in a loss of appetite and swelling of the abdomen as the body begins to break down the vital organs as a source of protein.

Sleep and Health

Infant Sleep

Infants 0 to 2 years of age sleep an average of 12.8 hours a day, although this changes and develops gradually throughout an infant’s life. For the first three months, newborns sleep between 14 and 17 hours a day, then they become increasingly alert for longer periods of time. About one-half of an infant’s sleep is rapid eye movement (REM) sleep, and infants often begin their sleep cycle with REM rather than non-REM sleep. They also move through the sleep cycle more quickly than adults. Parents spend a significant amount of time worrying about and losing even more sleep over their infant’s sleep schedule when there remains a great deal of variation in sleep patterns and habits for individual children. A 2018 study showed that at 6 months of age, 62% of infants slept at least six hours during the night, 43% of infants slept at least 8 hours through the night, and 38% of infants were not sleeping at least six continual hours through the night. At 12 months, 28% of children were still not sleeping at least 6 uninterrupted hours through the night, while 78% were sleeping at least 6 hours, and 56% were sleeping at least 8 hours.^[17]

The most common infant sleep-related problem reported by parents is nighttime waking. Studies of new parents and sleep patterns show that parents lose the most sleep during the first three months with a new baby, with mothers losing about an hour of sleep each night, and fathers losing a disproportionate 13 minutes. This decline in sleep quality and quantity for adults persists until the child is about six years old. ^[18]

While this shows there is no precise science as to when and how an infant will sleep, there are general trends in sleep patterns. Around six months, babies typically sleep between 14-15 hours a day, with 3-4 of those hours happening during daytime naps. As they get older, these naps decrease from several to typically two naps a day between ages 9-18 months. Often, periods of rapid weight gain or changes in developmental abilities such as crawling or walking will cause changes to sleep habits as well. Infants generally move towards one 2-4 hour nap a day by around 18 months, and many children will continue to nap until around four or five years old.^[19]

Sudden Unexpected Infant Deaths (SUID)

Each year in the United States, there are about 3,500 Sudden Unexpected Infant Deaths (SUID). These deaths occur among infants less than one-year-old and have no immediately obvious cause (CDC, 2015). The three commonly reported types of SUID are:

• Sudden Infant Death Syndrome (SIDS): SIDS is identified when the death of a healthy infant occurs suddenly and unexpectedly, and medical and forensic investigation findings (including an autopsy) are inconclusive. SIDS is the leading cause of death in infants up to 12 months old, and approximately 1,500 infants died of SIDS in 2013 (CDC, 2015). The risk of SIDS is highest at 4 to 6 weeks of age. Because SIDS is diagnosed when no other cause of death can be determined, possible causes of SIDS are regularly researched. One leading hypothesis suggests that infants who die from SIDS have abnormalities in the area of the brainstem responsible for regulating breathing (Weekes-Shackelford & Shackelford, 2005).

  Although the exact cause is unknown, doctors have identified the following risk factors for SIDS:

  • low birth weight
  • siblings who have had SIDS
  • sleep apnea
  • of African-American or Eskimo decent
  • low socioeconomic status (SES)
  • smoking in the home
• Unknown Cause: The sudden death of an infant less than one year of age that cannot be explained because a thorough investigation was not conducted and the cause of death could not be determined.
• Accidental Suffocation and Strangulation in Bed: Reasons for accidental suffocation include the following: Suffocation by soft bedding, another person rolling on top of or against the infant while sleeping, an infant being wedged between two objects such as a mattress and wall, and strangulation such as when an infant’s head and neck become caught between crib railings.

The combined SUID rate declined considerably following the release of the American Academy of Pediatrics safe sleep recommendations in 1992, which advocated that infants be placed on their backs for sleep (non-prone position). These recommendations were followed by a major Back to Sleep Campaign in 1994. According to the CDC, the SIDS death rate is now less than one-fourth of what is was (130 per 100,000 live birth in 1990 versus 40 in 2015). However, accidental suffocation and strangulation in bed mortality rates remained unchanged until the late 1990s. Some parents were still putting newborns to sleep on their stomachs partly because of past tradition. Most SIDS victims experience several risks, an interaction of biological and social circumstances. But thanks to research, the major risk, stomach sleeping, has been highly publicized. Other causes of death during infancy include congenital birth defects and homicide.

Co-Sleeping

The location of sleep depends primarily on the baby’s age and culture. Bed-sharing (in the parents’ bed) or co-sleeping (in the parents’ room) is the norm is some cultures, but not in others (Esposito et al. 2015) ^[20]. Colvin, Collie-Akers, Schunn and Moon (2014)^[21] analyzed a total of 8,207 deaths from 24 states during 2004–2012. The deaths were documented in the National Center for the Review and Prevention of Child Deaths Case Reporting System, a database of death reports from state child death review teams. The results indicated that younger victims (0-3 months) were more likely to die by bed-sharing and sleeping in an adult’s bed or on a person. A higher percentage of older victims (4 months to 364 days) rolled into objects in the sleep environment and changed position from side/back to prone. Carpenter et al. (2013)^[22] compared infants who died of SIDS with a matched control and found that infants younger than three months old who slept in bed with a parent were five times more likely to die of SIDS compared to babies who slept separately from the parents, but were still in the same room. They concluded that bed-sharing, even when the parents do not smoke or take alcohol or drugs, increases the risk of SIDS. However, when combined with parental smoking and maternal alcohol consumption and/or drug use, the risks associated with bed-sharing greatly increased.

Despite the risks noted above, the controversy about where babies should sleep has been ongoing. Co-sleeping has been recommended for those who advocate attachment parenting (Sears & Sears, 2001) ^[23] and other research suggests that bed-sharing and co-sleeping is becoming more popular in the United States (Colson et al., 2013) ^[24]. So, what are the latest recommendations?

The American Academy of Pediatrics (AAP) actually updated their recommendations for a Safe Infant Sleeping Environment in 2016. The most recent AAP recommendations on creating a safe sleep environment include:

• Back to sleep for every sleep. Always place the baby on his or her back on a firm sleep surface such as a crib or bassinet with a tight-fitting sheet.
• Avoid the use of soft bedding, including crib bumpers, blankets, pillows, and soft toys. The crib should be bare.
• Breastfeeding is recommended.
• Share a bedroom with parents, but not the same sleeping surface, preferably until the baby turns 1 but at least for the first six months. Room-sharing decreases the risk of SIDS by as much as 50 percent.
• Avoid baby’s exposure to smoke, alcohol, and illicit drugs.

As you can see, there is a recommendation to now “share a bedroom with parents,” but not the same sleeping surface. Breastfeeding is also recommended as adding protection against SIDS, but after feeding, the AAP encourages parents to move the baby to his or her separate sleeping space, preferably a crib or bassinet in the parents’ bedroom. Finally, the report included new evidence that supports skin-to-skin care for newborn infants.^[25]

Immunizations

Preventing communicable diseases from early infancy is one of the major tasks of the Public Health System in the USA. Infants mouth every single object they find as one of their typical developmental tasks. They learn through their senses and tasting objects stimulates their brain and provides a sensory experience as well as learning.

Infants have much contact with dirty surfaces. They lay on a carpet that most likely has been contaminated by adults walking on it; they mouth keys, rattles, toys, and books; they crawl on the floor; they hold on to furniture to walk, and much more. How do we prevent infants from getting sick? One possible answer is immunizations.

Many decades ago, our society struggled to find vaccines and cures for illnesses such as Polio, whooping cough, and many other medical conditions. A few decades ago parents started changing their minds on the need to vaccinate children. Some children are not vaccinated for valid medical reasons, but some states allow a child to be unvaccinated because of a parent’s personal or religious beliefs. At least 1 in 14 children is not vaccinated. What is the outcome of not vaccinating children? Some of the preventable illnesses are returning. Fortunately, each vaccinated child stops the transmission of the disease, a phenomenon called herd immunity. Usually, if 90% of the people in a community (a herd) are immunized, no one dies of that disease.

In 2017, Community Care Licensing in California, the agency that regulates childcare centers, changed regulations. Before it was possible for parents to opt-out of vaccinations due to personal beliefs, but this changed after Governor Brown signed a Bill in 2016 to only exclude children from being vaccinated if there were medical reasons. Furthermore, all personnel working with children must be immunized.