The Newborn & Normal Developmental Milestones

The arrival of a newborn indicates a journey of incredible growth and development, captivating both parents and nurses. As frontline caregivers, nurses play an essential role in monitoring and nurturing the optimal development of newborns. Understanding normal developmental milestones during the early weeks and months of life is important for the early detection of potential concerns and for providing supportive care.

This nursing note aims to explore the various newborn development, focusing on expected milestones in different areas including motor, language, cognitive, and social aspects.

Table of Contents

• Profile of the Newborn
  • Vital Statistics
  • Vital signs
• Adjustment to Extrauterine Life
• Appearance of the Newborn
• Normal Pediatric Developmental Milestones
• General Principles of Developmental Milestones
  • Domain #1: Normal Motor Development
  • Domain #2: Normal Language Development
  • Domain #3: Cognitive Development
  • Domain #4: Social Development

Profile of the Newborn

Newborns may look alike, but each has its own physical attributes and personalities. Some newborns are fat and short while some are long and thin. There are newborns who never give a fuss whenever they are changed or cuddled, but some can cry in high decibels whenever you lift them from their cradles.

• The weight of newborns varies according to their race, genetics, and nutritional factors.
• To determine if the newborn’s weight is appropriate for its gestational age, a neonatal graph should be used in plotting the newborn’s weight.
• Plotting the height and head circumference of the newborn also helps determine any disproportions.
• The average birth weight for a mature female newborn in the United States is 3.4kg or 7.5 lbs, and for a mature male, the newborn is 3.5 kg or 7.7 lbs.
• For all races, the normal weight is 2.5 kg or 5.5 lbs.
• The newborn loses 5% to 10% of its birth weight during the first few days of life, then has 1 day of stable weight, and gains weight rapidly afterward.
• The newborn must gain 2 lbs per month for the first six months of life.
• The average birth length of mature female newborns is 53 cm or 20.9 inches. The mature male newborn has an average birth length of 54 cm or 21.3 inches.
• A mature newborn has a head circumference of 34 to 35 cm.
• Head circumference is measured with a tape measure drawn across the center of the forehead and around the most prominent part of the posterior head.
• The chest circumference in a mature newborn is 2 cm less than the head circumference.
• Chest circumference is measured at the level of the nipple using a tape measure.

Vital Statistics

Vital signs

Adjustment to Extrauterine Life

• The newborn’s color in the first 15 to 30 minutes of life is still acrocyanotic, and after 2 to 6 hours, there are quick color changes that may occur with movement or crying.
• The temperature within the first 15 to 30 minutes after birth falls from the intrauterine temperature of 100.6⁰F or 38.1⁰C then stabilizes at 37.6⁰C after 2 to 6 hours.
• The rapid heart rate of as much as 180 BPM in the first 15 to 30 minutes of life will have wide swings in rate with activity as it slows to 120-140 BPM.
• The newborn’s respirations are irregular in the first few minutes of life, then slows to 30-60 breaths per minute after 30 minutes, and will become irregular again only during activity.
• The newborn would be alert in the first 15 to 30 minutes of life, and later on, will alternate between the sleeping and awakening phases.
• Just a few minutes after birth, the newborn would respond to stimulation vigorously but would be difficult to arouse while it is still on a resting period until it becomes responsive again 2 to 6 hours after birth.
• The bowel sounds can be heard after the first 15 minutes of life and becomes present afterward.

Appearance of the Newborn

• Increased concentration of red blood cells in newborns, and decreased amount of subcutaneous fat give newborns a ruddy complexion.
• In the first month, this ruddy complexion slightly fades.
• A pale and cyanotic newborn signifies that she may have poor central nervous system control.
• Gray color in newborns may indicate infection.
• Acrocyanosis is normal in a newborn, wherein the hands, feet, and lips are bluish in color.
• Central cyanosis, however, is a cause for concern as this may indicate a decrease in oxygenation.
• Jaundice appears on the second or third day of life as a result of the breakdown of fetal red blood cells.
• Early feeding to speed the passage of feces through the intestine and prevent reabsorption of bilirubin from the bowel may diminish physiologic jaundice.
• Pallor in newborns is a sign of anemia, and the newborn must be watched closely for signs of blood in the stool or vomitus.
• Harlequin sign or when a newborn who is lying on his or her side appears red on the dependent side and pale on the upper side does not have a clinical significance.
• Vernix caseosa or the white cream cheese-like substance is washed away in the first bath, but never rub harshly as it will only come off gradually.
• Lanugo or the fine, downy hair that covers the shoulders, arms and back of the newborn would be rubbed away by the friction of the bedding and clothes of the newborn.
• A white, pinpoint papule called milia can be found in some newborns, mainly on the cheek or the bridge of the nose, and they disappear by 2 to 4 weeks of age.

• The fontanelles or the spaces or openings where the skull bones join are soft spots on the newborn’s head.
  • The anterior fontanelle is located between the two parietal bones and the two frontal bones which gives it a diamond shape, and normally closes at 12 to 18 months of age.
  • The posterior fontanelle is located at the junction of the parietal bones and the occipital bone and is triangular in shape, and closes at the end of the second month.
• Newborns cry tearlessly until three months of age when the lacrimal ducts mature.
• Birthmarks
  • Hemangiomas are vascular tumors of the skin.
  • Nevus flammeus are muscular purple or dark red lesions. Generally appear on the face and thighs.
  • Strawberry hemangiomas—elevated areas formed by immature capillaries and endothelial cells.
  • Cavernous hemangiomas—these are dilated vascular spaces.
  • Mongolian spots—slate gray patches across the sacrum or buttocks and consist of a collection of pigment cells.
  • Forceps marks—these are circular or linear contusion matching the rim of the blade forceps on the infant’s cheeks.
• Permanent eye color appears in the 3^rd to 12th month of age.
• The newborn’s external ear is not yet fully formed, and the top part of the external ear should be on a line drawn from the inner canthus to the outer canthus of the eye and back across the side of the head.
• The newborn’s nose tends to look large for the face but the rest of the face will grow more than the nose does.
• The newborn’s mouth must open evenly when he or she cries.

Normal Pediatric Developmental Milestones

The development of a child mostly takes place in the early years of his life. At this stage, parents are still overwhelmed with how fast babies grow and develop. Parents take much time and patience in picking the best resource to understand a child’s development. Therefore, lots of questions are thrown in the air for the nurse to answer. Some questions prove to be challenging, and it is important for nurses to be able to know the normal developmental milestones like the back of their hands.

The first word, smile, and roll over are called developmental milestones. The child can tick off a milestone on his growing list of firsts depending on how he play, speak, move, and learn. While it is always emphasized that children develop at their own pace, developmental milestones are there to shed light on the general changes that should be expected as the child ages.

General Principles of Developmental Milestones

For excellent developmental assessment and surveillance, nurses must know the general principles of developmental milestones. The four key domains that should be periodically assessed include motor development, language development, problem-solving, and psychosocial skills.

Development occurs in an orderly, predictable, and intrinsic manner. For example, development proceeds from head to toe in a proximal to distal fashion. Reactions to stimuli develop from general into more specific and goal-directed reactions. Children gain independence from early years of total dependence.

Lastly, both intrinsic and extrinsic factors can affect development. Some examples of intrinsic factors are physical characteristics, health state, temperament, and genetic attributes. On the other hand, extrinsic factors include personalities of family members, economic status, learning experiences in the environment, and cultural setting to which the child is born. 

Domain #1: Normal Motor Development

Motor milestones can both be assessed through history interview and observation. Evaluating gross motor development usually involves neuro maturational markers like primitive reflexes and postural reactions.

For example, Moro reflex is one primitive reflex that is present at birth and disappears usually between 3-6 months of age. If the baby has stronger and more sustained primitive reflexes, a CNS injury might be considered. On the other hand, parachute reaction is one postural reaction that is acquired. This actually helps the body become oriented in space through an interplay of visual, proprioceptive, and vestibular adjustment done by cerebral and cerebellar brain structures. Delayed development of postural reactions can signify CNS damage.

On the other hand, fine motor skills involve the use of small muscles of the hands. The control progresses from the use of proximal muscles to the distal muscles. As the baby improves on balance during sitting and moving, the hands become more focused on manipulation of objects.

Here is a table of motor development milestones:

Red flags in motor development include 1) persistent fisting beyond 3 months which indicate neuromotor problems; 2) early rolling over, early pulling to stand instead of sitting, and persistent toe walking which may all indicate spasticity; and 3) early hand dominance (before 18 months of age), which may signify weakness of the opposite upper extremity associated with hemiparesis.

Domain #2: Normal Language Development

Language is the single best indicator of intellectual potential. Language is the ability to communicate with symbols. It is often mistaken as synonymous with speech, the latter being defined as a vocal expression of language. This is the domain with the most number of delays.

It is also interesting to note that a child can usually understand 10 times (receptive language) as many words as he or she can speak (expressive language). The first two (2) years of life is the time for optimal language acquisition.

Here is a table of basic language milestones:

Domain #3: Cognitive Development

This domain talks about thinking, memory, learning, and problem-solving. By evaluating problem solving and language milestones, infant intelligence can be estimated. There is a poor correlation between gross motor skills and cognitive potential.

Here is a table of cognitive concepts:

Domain #4: Social Development

It refers to the ability to interact with people and the environment. It is dependent on cultural and environmental factors. Here is a table of social milestones:

In the grand scheme of things, it is essential for nurses to understand normal development as well as the variations that are considered acceptable so nurses can recognize pathologic patterns and developmental delays. Prompt planning and intervention will then be instituted for children who may benefit from referral to early intervention programs.

The appearance of each newborn is unique in its own way, no matter how alike they seem to look. This is what makes them endearing to the people around them; their innocent personality and their tiny features would really make you love and care for them tenderly, whether you’re a family member or a healthcare provider.