,Chapter 1
The Beginning of Life: Pregnancy Through Preschool
Typical Board Question
While she previously slept in her own bed, after her parents' divorce, a 5-year-old girl begs to be allowed to sleep in her
mother's bed every night. She says that a "robber" is under her bed. She continues to do well in kindergarten and to play
with her friends. The best description of this girl's behavior is
separation anxiety disorder
normal behavior with regression
delayed development
lack of basic trust
attention deficit hyperactivity disorder (ADHD)
(See "Answers and Explanations" at end of chapter.)
I. CHILDBIRTH AND THE POSTPARTUM PERIOD
A. Birth rate and cesarean birth
1. About 4 million children are born each year in the United States; 23% of all births are by cesarean section.
2. The number of cesarean births declined from 1989 to 1996, partly in response to increasing evidence that women often
undergo unnecessary surgical procedures. Since 1996 the rate has been rising and is now as high as it was in 1989.
B. Premature birth
1. Premature births and very premature births are defined as those following a gestation of less than 37 and 32 completed
weeks, respectively.
2. Premature birth puts a child at greater risk for dying in the first year of life and for emotional, behavioral, and learning
problems; physical disability; and mental retardation.
3. Premature births, which are associated with low income, maternal illness or malnutrition, and young maternal age, occur in 6%
of births to white women and 13% of births to African American women.
4. The Apgar score (named for Dr. Virginia Apgar but useful as a mnemonic): A—appearance (color), P—pulse (heartbeat), G—grimace
(reflex irritability), A—activity (muscle tone), R—(respiration) measures physical functioning in premature and full-term newborns (
Table 1-1) and can be used to predict the likelihood of immediate survival.
P.2
TABLE 1-1 The Apgar Scoring System
Score
Measure 0 1 2
Heartbeat Absent Slow (< 100/min) Rapid (> 100/min)
Respiration Absent Irregular, slow Good, crying
Muscle tone Flaccid, limp Weak, inactive Strong, active
Color of body and Both body and Pink body, blue Pink body, pink
extremities extremities extremities extremities
pale or blue
, Reflexes, e.g., heel prick No response Grimace Foot withdrawal, cry,
or nasal tickle sneeze, cough
The infant is evaluated 1 minute and 5 (or 10) minutes after birth. Each of the five measures can have a score of 0 , 1, or 2 (highest
score = 10). Score > 7 = no imminent survival threat; score < 4 = imminent survival threat.
C. Infant mortality
1. Low socioeconomic status, which is related in part to ethnicity, is associated with prematurity and high infant mortality ( Table 1-
2).
2. In part because the United States does not have a system of health care for all citizens paid for by the government through taxes,
prematurity and infant mortality rates in the United States are high compared with rates in other developed countries (Figure 1-1).
TABLE 1-2 Ethnicity and Infant Mortality in the United States (2002)
Ethnic Group Infant Deaths per 1,000 Live Births
Asian or Pacific Islander 4.8
Hispanic/Latino 5.6
White 5.8
African American 13.9
Overall 7.0
, FIGURE 1-1. Comparison of national infant mortality rates: 1999. (Source: United Nations.)
D. Postpartum maternal reactions
1. Baby blues
a. Many women experience a normal emotional reaction called " baby blues" or " postpartum blues" lasting up to 2 weeks
after childbirth.
b. This reaction results from psychological factors (e.g., the emotional stress of childbirth, the feelings of added
responsibility), as well as physiological factors (e.g., changes in hormone levels, fatigue).
c. Treatment involves emotional support from the physician as well as practical suggestions for child care.
2. Major depression and brief psychotic disorder with postpartum onset (postpartum psychosis) are more serious reactions
than postpartum blues and are treated with anti-depressant and antipsychotic medications ( Table 1-3) (and see Chapters 11
and 12).
TABLE 1-3 Postpartum Maternal Reactions
Onset of
Maternal Reaction Incidence Symptoms Duration of Symptoms Characteristics
Postpartum 33%– Within a few Up to 2 weeks after Exaggerated emotionality
blues 50% days delivery and
("baby blues") after tearfulness
delivery Interacting well with friends
and family
Good grooming
Major 5%–10% Within 4 Up to 1 year without Feelings of hopelessness
depressive weeks treatment; 3–6 and helplessness
episode after weeks Lack of pleasure or interest
delivery with treatment in
usual activities
Poor self-care
May include psychotic
symptoms
("mood disorder with
psychotic
features"), e.g.,
hallucinations
and delusions (see Table
11-1 )
When psychotic, mother
may
harm infant
Brief psychotic 0.1%– Within 2–3 Up to 1 month Psychotic symptoms
disorder 0.2% weeks Not better accounted for by
(postpartum after mood
onset) delivery disorder with psychotic
features
Mother may harm infant
Women who have experienced these reaction once are at risk for having them after subsequent deliveries.
P.3
P.4
II. INFANCY: BIRTH TO 15 MONTHS
A. Bonding of the parent to the infant
The Beginning of Life: Pregnancy Through Preschool
Typical Board Question
While she previously slept in her own bed, after her parents' divorce, a 5-year-old girl begs to be allowed to sleep in her
mother's bed every night. She says that a "robber" is under her bed. She continues to do well in kindergarten and to play
with her friends. The best description of this girl's behavior is
separation anxiety disorder
normal behavior with regression
delayed development
lack of basic trust
attention deficit hyperactivity disorder (ADHD)
(See "Answers and Explanations" at end of chapter.)
I. CHILDBIRTH AND THE POSTPARTUM PERIOD
A. Birth rate and cesarean birth
1. About 4 million children are born each year in the United States; 23% of all births are by cesarean section.
2. The number of cesarean births declined from 1989 to 1996, partly in response to increasing evidence that women often
undergo unnecessary surgical procedures. Since 1996 the rate has been rising and is now as high as it was in 1989.
B. Premature birth
1. Premature births and very premature births are defined as those following a gestation of less than 37 and 32 completed
weeks, respectively.
2. Premature birth puts a child at greater risk for dying in the first year of life and for emotional, behavioral, and learning
problems; physical disability; and mental retardation.
3. Premature births, which are associated with low income, maternal illness or malnutrition, and young maternal age, occur in 6%
of births to white women and 13% of births to African American women.
4. The Apgar score (named for Dr. Virginia Apgar but useful as a mnemonic): A—appearance (color), P—pulse (heartbeat), G—grimace
(reflex irritability), A—activity (muscle tone), R—(respiration) measures physical functioning in premature and full-term newborns (
Table 1-1) and can be used to predict the likelihood of immediate survival.
P.2
TABLE 1-1 The Apgar Scoring System
Score
Measure 0 1 2
Heartbeat Absent Slow (< 100/min) Rapid (> 100/min)
Respiration Absent Irregular, slow Good, crying
Muscle tone Flaccid, limp Weak, inactive Strong, active
Color of body and Both body and Pink body, blue Pink body, pink
extremities extremities extremities extremities
pale or blue
, Reflexes, e.g., heel prick No response Grimace Foot withdrawal, cry,
or nasal tickle sneeze, cough
The infant is evaluated 1 minute and 5 (or 10) minutes after birth. Each of the five measures can have a score of 0 , 1, or 2 (highest
score = 10). Score > 7 = no imminent survival threat; score < 4 = imminent survival threat.
C. Infant mortality
1. Low socioeconomic status, which is related in part to ethnicity, is associated with prematurity and high infant mortality ( Table 1-
2).
2. In part because the United States does not have a system of health care for all citizens paid for by the government through taxes,
prematurity and infant mortality rates in the United States are high compared with rates in other developed countries (Figure 1-1).
TABLE 1-2 Ethnicity and Infant Mortality in the United States (2002)
Ethnic Group Infant Deaths per 1,000 Live Births
Asian or Pacific Islander 4.8
Hispanic/Latino 5.6
White 5.8
African American 13.9
Overall 7.0
, FIGURE 1-1. Comparison of national infant mortality rates: 1999. (Source: United Nations.)
D. Postpartum maternal reactions
1. Baby blues
a. Many women experience a normal emotional reaction called " baby blues" or " postpartum blues" lasting up to 2 weeks
after childbirth.
b. This reaction results from psychological factors (e.g., the emotional stress of childbirth, the feelings of added
responsibility), as well as physiological factors (e.g., changes in hormone levels, fatigue).
c. Treatment involves emotional support from the physician as well as practical suggestions for child care.
2. Major depression and brief psychotic disorder with postpartum onset (postpartum psychosis) are more serious reactions
than postpartum blues and are treated with anti-depressant and antipsychotic medications ( Table 1-3) (and see Chapters 11
and 12).
TABLE 1-3 Postpartum Maternal Reactions
Onset of
Maternal Reaction Incidence Symptoms Duration of Symptoms Characteristics
Postpartum 33%– Within a few Up to 2 weeks after Exaggerated emotionality
blues 50% days delivery and
("baby blues") after tearfulness
delivery Interacting well with friends
and family
Good grooming
Major 5%–10% Within 4 Up to 1 year without Feelings of hopelessness
depressive weeks treatment; 3–6 and helplessness
episode after weeks Lack of pleasure or interest
delivery with treatment in
usual activities
Poor self-care
May include psychotic
symptoms
("mood disorder with
psychotic
features"), e.g.,
hallucinations
and delusions (see Table
11-1 )
When psychotic, mother
may
harm infant
Brief psychotic 0.1%– Within 2–3 Up to 1 month Psychotic symptoms
disorder 0.2% weeks Not better accounted for by
(postpartum after mood
onset) delivery disorder with psychotic
features
Mother may harm infant
Women who have experienced these reaction once are at risk for having them after subsequent deliveries.
P.3
P.4
II. INFANCY: BIRTH TO 15 MONTHS
A. Bonding of the parent to the infant
