Peds chapter 4

Toddler age

1-3 years

Emotional and social development

Emotional development in the toddler years is focused on separation and individuation (Papalia & Feldman, 2011). Seeing oneself as separate from the parent or primary caregiver is accompanied by forming a sense of self and learning to exert control over one's environment. As this need to feel in control of his or her world emerges, the toddler displays egocentrism (focus on self). This need for control results in emotional lability: very happy and pleasant one moment, then overreacting to limit setting with a temper tantrum in the next moment (Brazelton & Sparrow, 2006). As toddlers identify the boundaries between themselves and the parent or primary caregiver, they learn to negotiate a balance between attachment and independence. Toddlers initially rely on the parents' communication and signals in order to initiate appropriate behavior or inhibit undesirable behavior. They have a difficult time choosing between sets of behaviors as they occur in different situations. Power struggles often occur in this age group, and it is important for parents and caregivers to thoughtfully and intentionally develop the rituals and routines that will provide stability and security for the toddler (Feigelman, 2011b). Many toddlers rely on a security item (blanket, doll, or bear) to comfort themselves in stressful situations (Fig. 4.5). This ability to self-soothe is a function of autonomy and is viewed as a sign of a nurturing environment, rather than, as one might suspect, one of neglect. (Kyle 103) Children also begin to learn about gender differences in the toddler years. They observe the differences between male and female body parts if they are exposed to them. Toddlers may question parents about these differences and may begin to explore their own genitals. Toddlers also begin to understand and mimic social gender differences. They make observations about gender-specific behavior dependent upon what they are exposed to. Aggressive behaviors are typically displayed during the toddler years. Toddlers may hit, bite, or push other children and grab toys. Adults can assist the toddler in building empathy by pointing out when someone is hurt and explaining what happened. Toddlers should not be blamed for their impulsive behavior; rather, they should be guided toward socially acceptable actions in order to foster development of appropriate social judgment. It is particularly important for the parent or caregiver to serve as a role model for appropriate behavior, rather than losing his or her own temper, in order for the toddler to be able to learn how to acceptably handle frustrations. Offering limited choices is one way of allowing toddlers some control over their environment and helping them to establish a sense of mastery. Since toddlers naturally have a short attention span, they tend to dawdle. As the toddlers become more self-aware, they start to develop emotions of self-consciousness such as embarrassment and shame. Though toddlers are becoming more self-aware, they still do not have clear body boundaries. They do not clearly understand the body's functions, though they are beginning to make appropriate connections. Feces may be viewed as a part of the child, and the toddler may become upset at seeing it disappear in the toilet. The toddler will protect his or her body by resisting intrusive procedures such as temperature or blood pressure measurement. (Kyle 103-104) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Toilet teaching

When myelination of the spinal cord is achieved around age 2 years, the toddler is capable of exercising voluntary control over the sphincters. Girls may be ready for toilet teaching earlier than boys. Toddlers are ready for toilet teaching when: Bowel movements occur on a fairly regular schedule. The toddler expresses knowledge of the need to defecate or urinate. This may be through verbalization, change in activity, or gestures such as: Looks into or grabs diaper Squats Crosses legs Grimaces and/or grunts Hides behind a door or the couch when defecating The diaper is not always wet (this indicates the ability to hold the urine for a period of time). The toddler is willing to follow instructions. The toddler walks well alone and is able to pull down his or her pants. The toddler follows caregivers to the bathroom. The toddler climbs onto the potty chair or toilet (AAP, 2015f). Parents should approach toilet teaching with a calm, positive, and nonthreatening manner. Initially it may be helpful to allow the toddler to observe a same-sex family member using the toilet. Start with the toddler fully clothed on the potty chair or toilet while the parent or caregiver talks about what the toilet is used for and when. The toddler will feel most comfortable with a toddler potty chair that sits on the floor (Fig. 4.13). If a potty chair is unavailable, facing toward the toilet tank may make the toddler feel more secure, as the buttocks remain on the front of the seat rather than sinking through the toilet seat opening. After a week or longer, remove a dirty diaper and place the contents in the toilet. Next, try having the toddler sit on the potty chair or toilet without pants or diaper on. The toddler may benefit from watching a caregiver or friend use the toilet. It may also be beneficial to demonstrate using the potty chair with a baby doll that wets. (Kyle 117) Parents should always use gentle praise and no reproaches. Usually the best time to achieve success with defecation on the toilet is following a meal. When the toddler has achieved success with bowel control, bladder control will come next. It may be many months before nighttime bladder control is achieved, and the toddler may still require a diaper at night. Parents should use appropriate words for body parts, urination, and defecation, then use those words consistently so the toddler understands what to say and do (AAP, 2015f). After a couple of weeks of successful toileting, the toddler may start wearing training pants. When toddlers have an accident and do not make it to the toilet, gently remind them about toileting and let them help clean up. Toddlers should never be punished for bowel or bladder "accidents." With so much attention focused on the genitalia during toilet teaching and the frequency of being without a diaper, it is natural for toddlers to become more focused on their own genitalia. Boys and girls both will explore their genitalia and discover the resulting pleasurable sensation. Masturbation in the toddler often causes a great deal of discomfort in the parent. The parent should not draw attention to the activity, as that may increase its frequency. The parent should calmly explain to the toddler that this is an activity that may only be done in private (Feigelman, 2011b). If the toddler is masturbating excessively or refuses to stop when in public, then there may be additional stressors in the toddler's life that should be explored. (Kyle 118) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Separation anxiety

As toddlers become increasingly skilled at mobility, they realize that if they have the capability of leaving, then so does the parent. As self-awareness develops and conflicts over closeness versus exploration occur, separation anxiety may re-emerge in the 18- to 24-month period (Brazelton & Sparrow, 2006). Power struggles may escalate and distress at separating from the parent may increase. Again, a predictable routine with appropriate limit setting may help toddlers to feel safer and more secure during this period. From the age of 24 to 36 months, separation anxiety again eases. The older toddler begins to have a concept of object constancy: he or she has an internal representation of the parent or caregiver and is better able to tolerate separation, knowing that a reunion will occur. (Kyle 104) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Genitourinary system

Bladder and kidney function reach adult levels by 16 to 24 months of age. The bladder capacity increases, allowing the toddler to retain urine for increased periods of times. Urine output should be about 1 mL/kg/hour. The urethra remains short in both the male and female toddler, making them more susceptible to urinary tract infections compared to adults. (Kyle 98) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Safety in water

Drowning is the leading cause of unintentional injury and death in US children, with nearly half of drowning victims being 4 years old and younger (Safe Kids, 2015b). Drowning may occur in very small volumes of water such as a toilet, bucket, or bathtub, as well as the obvious sites such as swimming pools and other bodies of water. Toddlers' large heads in relation to their body size place them at risk for toppling over into a body of water that they are inquisitive about. Toddlers should be supervised at all times when in or around the water. In general, most children do not have the physical and cognitive capabilities necessary to truly learn how to swim until 4 years of age. Parents who want to enroll a toddler in a swimming class should be aware that a water safety skills class would be most appropriate. However, even toddlers who have completed a swimming program still need constant supervision in the water (Safe Kids, 2015c). Box 4.3 gives recommendations for the prevention of drowning. (Kyle 110) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

promoting appropriate discipline

Discipline is a common concern during toddlerhood. The toddler's intense personality and extreme emotional reactions can be difficult for parents to understand and cope with. The toddler needs firm, gentle guidance to learn what the expectations are and how to meet them. The parent's love and respect for the toddler teach the toddler to care about himself or herself and for others. Affection is as important as the guidance aspect of discipline. Having realistic expectations of what the toddler is capable of learning and understanding can help the parent in the disciplinary process. The toddler's intense push for autonomy can often test a parent's limits. The easygoing infant usually becomes more challenging in toddlerhood. The toddler's continual quest for new experiences often places the toddler at risk, and his or her negativism very often taxes the parent's patience. In an effort to prevent the toddler from experiencing harm and in response to his or her continual testing of limits, parents often resort to spanking. Though commonly accepted, the AAP and the NAPNAP recommend against corporal or physical punishment (American Academy of Child and Adolescent Psychiatry, 2012; NAPNAP, 2011). Recent research points out the dangers inherent in the use of corporal punishment as well as the possibilities for negative effects on the child's future behavior (Box 4.5). Spanking or other forms of corporal punishment lead to a pro-violence attitude, create resentment and anger in some children, and contribute to the cycle of violence (NAPNAP, 2011). Take Note! Toddlers younger than 18 months of age should NEVER be spanked, as there is an increased possibility of physical injury in this age group. Also, the infant/young toddler is not capable of linking the spanking with the undesired behavior (Lyness, 2013). Normal toddler development includes natural curiosity, and this curiosity often results in dangerous or problematic activities for the toddler (Lyness, 2013). Toddlers have a difficult time learning the rules and, in general, do not behave badly intentionally. Providing a childproof environment will allow the toddler to participate in safe exploration, which will meet his or her developmental needs and decrease the frequency of intervention needed on the part of the parents. Discipline should focus on limit setting, negotiation, and techniques to assist the toddler to learn problem solving. Parents should provide consistency and commit to the limits that are set. Offering realistic choices helps give the toddler a sense of mastery. Rules should be simple and limited in number. Maintaining the toddler's schedule of meals and rest/sleep will help to prevent conflicts that occur as a result of hunger or fatigue. Toddlers should not be made to share, as this is a concept they do not understand. Parents should encourage simple activities enjoyed by the children involved and avoid confrontation over toys. Parents should offer toddlers appropriate choices to help them develop autonomy, but should not offer a choice when none exists. (Kyle 116) Positive reinforcement should be used as much as possible. "Catching" a child being good helps to reinforce appropriate or desirable behaviors. When the toddler is displaying appropriate behavior, the parent should reward the child consistently with praise and physical affection. "Time-out" can be used effectively at around 2.5 to 3 years of age (refer to Chapter 5 for details). "Extinction" is a particularly useful technique with 2- and 3-year-olds. Extinction involves systematic ignoring of the undesired behavior. Parents sometimes unknowingly contribute to the occurrence of an unwanted behavior simply by the attention they give the toddler (even if it is negative in nature, it is still attention). Parents who want to extinguish an annoying (nondangerous) behavior should resolve to ignore it every time it occurs. When the child withholds the behavior or performs the opposite (appropriate) behavior, they should use compliments and praise. It may be difficult to ignore a difficult behavior, but the results are well worth the effort. Teaching Guidelines 4.4 provides tips on avoiding power struggles and offering appropriate guidance to toddlers. (Kyle 116-117) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Fine motor skills

Fine motor skills in the toddler period are improved and perfected. Holding utensils requires some control and agility, but even more is needed for buttoning and zipping. Adequate vision is necessary for the refinement of fine motor skills because eye-hand coordination is crucial for directing the fingers, hand, and wrist to accomplish small muscle tasks such as fitting a puzzle piece or stringing a bead. See Table 4.2 for age expectations for various motor skills. (Kyle 100) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

preventing overweight and obesity

In the child younger than 3 years of age, the greatest risk factor for the development of overweight or obesity is having a parent with a high body mass index (BMI) (Dev, et al., 2013). The nurse can screen for overweight in the child older than 2 years of age by calculating the BMI and plotting the BMI on the standardized age- and gender-appropriate growth charts (see Appendix A for growth charts, and refer to Chapter 10 for BMI calculation instructions). Trends over time may be predictive of the development of overweight or obesity. Another factor in development of obesity in young children is juice intake (Stettler, et al., 2011). Since most young children like the sweet taste of juice, they may drink excessive amounts of it. Toddlers who drink excess fruit juice and eat well may develop overweight or obesity because of the high sugar content in the juice. On the other end of the spectrum, some children may actually feel full from juice consumption and decrease their intake of solid foods. These children are at risk for malnutrition. Fruit juice intake should be limited to 4 to 6 ounces per day. See Evidence-Based Practice 4.1. (Kyle 113) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Communication and language development

Language development occurs rapidly during the toddler years. The acquisition of language is a dynamic and complex process. The child's age and social interactions and the types of language to which he or she has been exposed influence language development. Receptive language development (the ability to understand what is being said or asked) is typically far more advanced than expressive language development (the ability to communicate one's desires and feelings) (Feigelman, 2011b; Goldson & Reynolds, 2014). In other words, the toddler understands language and is able to follow commands far sooner than he or she can actually use the words himself or herself. Language is a very important part of the toddler's ability to organize his or her world and actually make sense of it. Thoughtfully planned use of language can provide behavior guidance and contribute to the avoidance of power struggles. In regard to expressive language development, the young toddler begins to use short sentences and will progress to a vocabulary of 50 words by 2 years of age (Feigelman, 2011b; Goldson & Reynolds, 2014). Echolalia (repetition of words and phrases without understanding) normally occurs in toddlers younger than 30 months of age. "Why" and "what" questions dominate the older toddler's language. Telegraphic speech is common in the 3-year-old. Telegraphic speech refers to speech that contains only the essential words to get the point across, much like a telegram. Rather than "I want a cookie and milk," the toddler might say, "Want cookie milk." In telegraphic speech the nouns and verbs are present and are verbalized in the appropriate order (Feigelman, 2011b). Table 4.3 gives an overview of receptive and expressive language development in the toddler. Early identification and referral of children with potential speech delays is critical. If a delay is identified, early intervention may increase the child's potential to acquire age-appropriate receptive and expressive language skills. Children with pre-existing conditions such as genetic syndromes that are known to have an effect on language development should be referred to a speech-language pathologist as soon as the condition is recognized rather than waiting until the child exhibits a delay. (Kyle 101-102) Of special concern in the toddler years is the development of speech and language in potentially bilingual children. At the age of 1 to 2 years, the potentially bilingual child may blend two languages—that is, parts of the word in both languages are blended into one word. At age 2 to 3 years, the potentially bilingual toddler may mix languages within a sentence. Thus, the assessment of adequate language development is more complicated in bilingual children. There are websites that may be helpful to parents of potentially bilingual children, where they can find support and resources. A list of websites is included on at http://thePoint.lww.com/Kyle3e. (Kyle 102-103) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

promoting growth and development through play

Play is the major socializing medium for toddlers. Parents should limit television viewing and encourage creative and physical play instead. Toddlers typically play alongside another child (parallel play) rather than cooperatively (Fig. 4.7). The short attention span of the toddler will make him or her often change toys and types of play. It is important to provide a variety of safe toys to allow the toddler many different opportunities for exploring the environment. Toddlers do not need expensive toys; in fact, regular household items sometimes make the most enjoyable toys. Toddlers are egocentric, a normal part of their development (Piaget, 1969). This makes it difficult for them to share. As they are developing a sense of self (who they are as a person), they may see their toys as an extension of themselves. Learning to share occurs in later toddlerhood. Toddlers also like dramatic play and play that recreates familiar activities in the home. Toddlers like to listen to music of all kinds and will often dance to whatever they hear on the radio. Toddlers enjoy drums, xylophones, cymbals, and toy pianos. Musical instruments made at home are also enjoyed. A few pebbles or coins inside an empty water bottle with the top tightly secured is a great music maker; an empty butter tub with a lid and a pair of wooden spoons makes a nice drum. (Kyle) Adequate physical activity is necessary for the development and refinement of movement skills. Toddlers need at least 30 minutes of structured physical activity and anywhere from 1 to several hours of unstructured physical activity per day (Gavin, 2014a). Indoor and outdoor play areas should encourage play activities that use the large muscle groups. The activity must occur within a safe environment. Outdoor play structures should be positioned over surfaces that are soft enough to absorb a fall, such as sand, wood chips, or sawdust (Fig. 4.8). Box 4.1 lists recommended age-appropriate toys. (Kyle 106) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Encouraging reading

Reading to the toddler every day is one of the best ways to promote language and cognitive development (Fig. 4.9). Toddlers particularly enjoy homemade or purchased books about feelings, family, friends, everyday life, animals and nature, and fun and fantasy. Board books have thick pages that are easier for young toddlers to turn; older toddlers can turn paper pages one at a time. The toddler may also enjoy "reading" the story to the parent. Reach Out and Read, a program designed to promote early literacy, offers tips for reading with young children (see Teaching Guidelines 4.1). (Kyle 107) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Promoting safety

Safety is of prime concern throughout the toddler period. Curiosity, mobility, and lack of impulse control all contribute to the incidence of unintentional injury in toddlerhood. Even the most watchful and caring parents have toddlers who run into the street, otherwise disappear from parents, and fall down the stairs. Toddlers require direct observation and cannot be trusted to be left alone. A childproof environment provides a safe place for the toddler to explore and learn. Motor vehicle accidents, drowning, choking, burns, falls, and poisoning are the most common injuries suffered by toddlers. Safety and injury prevention focus on these categories. (Kyle 108) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Cardiovascular system

The heart rate decreases and blood pressure increases in toddlerhood. Blood vessels are close to the skin surface and so are compressed easily when palpated. (Kyle 98) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Respiratory system

The respiratory structures continue to grow and mature throughout toddlerhood. The alveoli continue to increase in number, not reaching the adult number until about 7 years of age. The trachea and lower airways continue to grow but remain small compared with the adult. The tongue is relatively large in comparison to the size of the mouth. Tonsils and adenoids are large and the Eustachian tubes are relatively short and straight. (Kyle 97) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Safety in the car

The safest place for the toddler to ride is in the back seat of the car. Parents should use the appropriate size and style of car seat for the child's weight and age as required by state law. At a minimum, toddlers should be in a rear-facing car seat with harness straps and a clip until 2 years of age (American Academy of Pediatrics [AAP], 2015a). After age 2 years, a forward-facing seat may be used. A toddler riding in a pickup truck should never ride in the cargo area or truck bed. A full rear seat in the truck is the preferred placement for the toddler car seat. If an appropriate rear seat is unavailable, the air bag should be disarmed and the forward-facing car seat should be secured appropriately in the truck seat. The lower anchor and top tether are additionally required for all forward-facing car seats manufactured since 2002 and are accommodated by motor vehicles manufactured since that time (Fig. 4.10). In older vehicles or car seats, seat belts are utilized for installation. Drivers should avoid using the cell phone or attempting to intervene with the children while they are driving. Excellent resources about car seat safety appropriate for both parents and professionals can be found on . (Kyle 108) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

gastrointestinal system

The stomach continues to increase in size, allowing the toddler to consume three regular meals per day. Pepsin production matures by 2 years of age. The small intestine continues to grow in length, though it does not reach the maximum length of 2 to 3 m until adulthood. Stool passage decreases in frequency to one or more per day. The color of the stool may change (yellow, orange, brown, or green) depending on the toddler's diet. Since the toddler's intestines remain somewhat immature, the toddler often passes whole pieces of difficult-to-digest food such as corn kernels. Bowel control is generally achieved by the end of the toddler period. (Kyle 98) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Weaning

The timing of weaning from breastfeeding is influenced by a number of factors such as cultural beliefs, local and regional ethnic beliefs, the mother's work schedule, desired child spacing, or societal feelings about the nature of the mother-infant relationship. The AAP recommends breastfeeding for at least 12 months, then for as long as is mutually agreeable to mother and child (AAP, 2012). Extending breastfeeding into toddlerhood is believed to be beneficial to the child. Extended breastfeeding provides nutritional, immunologic, and emotional benefits to the child. Contrary to popular belief, it is biologically possible to become pregnant while breastfeeding. Breastfeeding a newborn appropriately can occur while continuing to nurse the older sibling. Weaning from breastfeeding tends to occur earlier in the United States than in countries around the world, despite recommendations on length of breastfeeding by a number of organizations. Most professional organizations recommend breastfeeding for at least 1 year (National Association of Pediatric Nurse Practitioners [NAPNAP], 2013). Weaning is a highly individualized decision. Educate the mother about the benefits of extended breastfeeding and support her in her decision to wean at a given time. Weaning from the bottle should occur by 12 to 15 months of age. Prolonged bottle-feeding is associated with the development of dental caries. No-spill "sippy cups" contain a valve that requires sucking by the toddler in order to obtain fluid, thus functioning similar to a baby bottle. Hence, no-spill sippy cups can also be associated with dental caries and are not recommended (American Academy of Pediatric Dentistry [AAPD], 2014). Cups with spouts that do not contain valves are acceptable. The 12- to 15-month-old is developmentally capable of consuming adequate fluid amounts using a cup (Kyle 111) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Promoting nutrition

The toddler's ability to chew and swallow is improving, and he or she learns to use utensils effectively to feed himself or herself. The early years lay a foundation for the future, and a great deal of parental and societal interest is focused on nutrition and eating. Forming healthy eating habits has its foundation early in life, and diet has significant influence upon the child's future health status. By establishing healthier food choice patterns early in life, the child is better able to continue these healthy choices later in life. The child younger than 2 years of age should not have his or her fat intake restricted, but this does not mean that unhealthy foods such as sweets should be eaten liberally. A diet high in nutrient-rich foods and low in nutrient-poor high-calorie foods such as sweets is appropriate for children of all ages. See Healthy People 2020. (Kyle 110-111) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Physical growth

The toddler's height and weight continue to increase steadily, though the increase occurs at a slower velocity compared to infancy. Toddler gains in height and weight tend to occur in spurts, rather than in a linear fashion (Fig. 4.1). The average toddler weight gain is 1.36 to 2.27 kg (3 to 5 lb) per year. Length/height increases by an average of 7.62 cm (3 inches) per year. Toddlers generally reach about half of their adult height by 2 years of age. Head circumference increases about 2.54 cm (1 inch) from when the child is between 1 and 2 years of age, then increases an average of 1.27 cm (a half inch) per year until age 5. The anterior fontanel should be closed by the time the child is 18 months old. Head size becomes more proportional to the rest of the body near the age of 3 years (Feigelman, 2011a; Feigelman, 2011b; Goldson & Reynolds, 2014). (Kyle 97) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Motor skills development

Toddlers continue to gain new motor skills as well as refine others. Walking progresses to running, climbing, and jumping. Pushing or pulling a toy, throwing a ball, and pedaling a tricycle are accomplished in toddlerhood. Fine motor skills progress from holding and pinching to the ability to manage utensils, hold a crayon, string a bead, and use a computer. Development of eye-hand coordination is necessary for the refinement of fine motor skills. These increased abilities of mobility and manipulation help the curious toddler explore and learn more about his or her environment (Fig. 4.3). As the toddler masters a new task, he or she has confidence to conquer the next challenge. Thus, mastery in motor skill development contributes to the toddler's growing sense of self-esteem. The toddler who is eager to face challenges will likely develop more quickly than one who is reluctant. The senses of sight, hearing, and touch are useful in helping to coordinate gross and fine motor movement. (Kyle 99) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

cognitive development

According to Jean Piaget (1969), toddlers move through the last two substages of the first stage of cognitive development, the sensorimotor stage, between 12 and 24 months of age. Young toddlers engage in tertiary circular reactions and progress to mental combinations. Rather than just repeating a behavior, the toddler is able to experiment with a behavior to see what happens. By 2 years of age, toddlers are capable of using symbols to allow for imitation. With increasing cognitive abilities, toddlers may now engage in delayed imitation. For example, they may imitate a household task that they observed a parent doing several days ago. Piaget identified the second stage of cognitive development as the preoperational stage. It occurs in children between ages 2 and 7 years. During this stage toddlers begin to become more sophisticated with symbolic thought. The thinking of the older toddler is far more advanced than that of the infant or young toddler, who views the world as a series of objects. During the preoperational stage, objects begin to have characteristics that make them unique from one another. Objects are considered large or small, having a particular color or shape, or having a unique texture. This moves beyond the connection of sensory information and physical action. Words and images allow the toddler to begin this process of developing symbolic thought by providing a label for the objects' characteristics (Piaget, 1969). Toddlers also use symbols in dramatic play. First they imitate life with appropriate toy objects, and then they are able to substitute objects in their play. A bowl may be used to pretend to eat from, but then later it can be used upside down on the head as a hat (Fig. 4.2). Human feelings and characteristics may also be attributed to objects (animism) (Papalia & Feldman, 2011). See Table 4.1 for further explanation of cognitive development in toddlerhood. (Kyle 98) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Teaching about nutritional needs

Adequate calcium intake and appropriate exercise lay the foundation for proper bone mineralization. The toddler requires an average intake of 500 mg calcium per day (Ross, Taylor, Yaktine, & Del Valle, 2014). Dairy products are considered the primary sources of dietary calcium. One cup of low-fat or whole milk, 8 ounces of low-fat yogurt, and 1½ ounces of cheddar cheese each provide 300 mg of calcium. Broccoli, oranges, sweet potatoes, tofu, and dried beans or legumes are also good sources of calcium (35- to 120-mg calcium per serving). (Kyle 111) Iron-deficiency anemia in the first 2 years of life may be associated with developmental and psychomotor delays (Baker & Greer; Committee on Nutrition AAP, 2010). Although it is important for toddlers to consume adequate amounts of iron, they tend to have the lowest daily iron intake of any age group. When breastfeeding or formula-feeding ends (most often at 1 year of age), it is often replaced with iron-poor cow's milk. Limiting milk intake to 16 ounces per day, as well as limiting juice intake, can be helpful. Encourage the parents to provide iron-fortified cereals and other foods rich in iron and vitamin C. (Kyle 111) Fat or cholesterol intake should not be restricted in children younger than age 2 years. The first 2 years of life require high energy intake because they are a time of very rapid growth and development. To promote healthy cholesterol levels, children older than age 2 years should consume a diet with a total fat content between 20% and 30% of total calories. Saturated fats should account for less than 10% of total calories (Stettler, et al., 2011). Due to daily variations and the pickiness of the toddler, fat intake should be evaluated over a period of several days. The daily recommended intake of fiber for a 1- to 3-year-old is 19 g. Generally, toddler serving sizes should be about two-thirds that of an older child. Box 4.4 lists common sources of several nutrients. (Kyle 111-112) Parents should encourage toddlers to drink water. Juice intake should be limited to 4 to 6 ounces per day. Milk intake should be limited to 16 to 24 ounces per day. Juice and milk should be served along with meals or snacks. Water should be offered for between-meal drinking. Toddlers should drink from a cup. (Kyle 112) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Gross motor skills

As gross motor skills are mastered and then used repeatedly, the large muscle groups in the toddler are strengthened. The "toddler gait" is characteristic of new walkers. The toddler does not walk smoothly and maturely. Instead, the legs are planted widely apart, toes are pointed forward, and the toddler seems to sway from side to side while moving forward (Fig. 4.4). Often, the toddler seems to speed along, be pitching forward, and may appear ready to topple over at any moment. The toddler may fall often, but will use outstretched arms to catch himself or herself (parachute reflex). After about 6 months of practice walking, the toddler's gait is smoother and the feet are closer together. By 3 years of age, the toddler walks in a heel-to-toe fashion similar to that of adults. Toddlers often use physical actions such as running, jumping, and hitting to express their emotions because they are only just learning to express their thoughts and feelings verbally. Table 4.2 lists motor skill expectations in relation to age. (Kyle 99-100) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Preventing poisoning

As toddlers become more mobile, they are increasingly able to explore their environment and more easily and efficiently gain access to materials that may be unsafe for them to handle. Their natural curiosity leads them into situations that may place them in danger. Poor taste discrimination in this age group allows for ingestion of chemicals or other materials that older children would find too unpleasant to swallow. Box 4.2 lists most potentially dangerous ingested poisons. Discuss poison prevention in the home at each well-child visit (see Healthy People 2020). The AAP (2015e) recommends that potentially poisonous substances (e.g., medications, cleaners, hair care products, car care products) be stored out of the toddler's teach, out of the toddler's sight, and in a childproof, locked cabinet. (Kyle 109 Encourage all families to take the following safety measures: Store all substances in original containers only. Never store any liquid other than soda in a soda pop bottle. Do not allow toddlers access to baby powder, lotion, cream, or other toddler hygiene products. Ensure all medications have child-safety caps. Do not leave within the toddler's reach medications such as lozenges or samples that are not packaged in safety bottles. Be very careful with medications that are provided in transdermal patch form. Do not refer to medicines as candy, as the toddler may mistake pills for candy and ingest them. Do not expose toddlers to hazardous vapors such as paints, cleaners, tobacco smoke, and especially street drugs such as crack and marijuana. Keep "button" batteries secured and away from a toddler's reach. Keep house plants off the floor, remove them from the home, or hang them or place them on a high shelf (American Association of Poison Control Centers, n. d.; AAP, 2015e). (Kyle 110) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Neurologic system

Brain growth continues through toddlerhood, and head circumference (reflective of brain growth) reaches about 90% of its adult size by 2 years of age (Zero to Three, 2014a; Feigelman, 2011b). Myelination of the brain and spinal cord continues to progress and is complete around 24 months of age. Myelination results in improved coordination and equilibrium as well as the ability to exercise sphincter control, which is important for bowel and bladder mastery. Integration of the primitive reflexes occurs in infancy, allowing for the emergence of the protective reflexes near the end of infancy or early in toddlerhood. The forward or downward parachute reflex is particularly helpful when the child starts to toddle. Rapid increase in language skills is evidence of continued progression of cognitive development. (Kyle 97) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Promoting healthy teeth and gums

By 30 months of age, the toddler should have a full set of primary ("baby") teeth. Parents may not be aware of the importance of preventing cavities in primary teeth since they will eventually be replaced by the permanent teeth. Poor oral hygiene, prolonged use of a bottle or no-spill sippy cup, lack of fluoride intake, and delayed or absent professional dental care may all contribute to the development of dental caries (AAP, n. d.). Cleaning of the toddler's teeth should progress from brushing with simply water to using a very small amount (pea-sized) of fluoridated toothpaste with brushing beginning at 2 years of age (Fig. 4.12). Weaning from the bottle no later than 15 months of age and severely restricting use of a no-spill sippy cup (the kind that requires sucking for fluid delivery) is recommended. p. 114 p. 115 FIGURE 4.12 The parent should brush the toddler's teeth to ensure proper cleaning of the teeth, gums, and tongue. Use only water for brushing before 2 years of age and a pea-sized amount of fluoride-containing toothpaste after age 2 years. At age 1 year, the toddler should have his or her first dentist visit to establish current health of the teeth and gums. Eating should be limited to meal and snack times, as "grazing" throughout the day exposes the teeth to food throughout the day. Carbohydrate-containing foods combined with oral bacteria create a decreased oral pH level that is optimal for the development of dental caries (cavities). See Healthy People 2020. (Kyle 114-115) Public water fluoridation is a public health initiative that ensures that most children receive adequate fluoride intake to prevent dental caries. Table 4.5 gives recommendations regarding fluoride supplementation. If the water supply contains adequate fluoride, no other supplementation is necessary other than brushing with a small amount of fluoride-containing toothpaste after age 2 years. Excess fluoride ingestion should be avoided, as it contributes to the development of fluorosis (mottling of the enamel). Fluorosis occurs most often in the toddler years (AAP, 2012). Risk factors for fluorosis development include: High fluoride levels in the local water supply Use of fluoride-containing toothpaste prior to age 2 years Excessive ingestion of fluoride either in toothpaste or foods Fluoride-containing foods: tea, ready-to-eat infant foods containing chicken, white or purple grape juice, and beverages, processed foods, and cereals that were manufactured with fluoride-containing water (Kyle 115) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Cultural influences on growth and development

Homelessness or poverty may directly influence the toddler's ability to grow adequately, as resources for the purchase and preparation of appropriate food may be lacking. Appropriate toys (safe ones) may also not be available in those situations. Food customs continue to have an impact on the child's diet and ability to ingest appropriate nutrients. Individual families' value systems have an impact on the toddler's development as well. Some parents desire to keep their child a "baby" for a longer period, thus delaying weaning or continuing to feed the child baby food or puréed food for a longer period. Other families may highly value independence and encourage the toddler to walk everywhere on his or her own rather than carrying the child. Culture may also affect emotional development. Some families start at a very young age to discourage crying in boys, encouraging them to "act like a big boy" or "be a man." Ridicule for crying at this age may hurt the toddler's self-concept. Educating families about normal growth and development while continuing to value and support cultural practices is important (Papalia & Feldman, 2011). (Kyle 104-105) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Fears

Common fears of toddlers include loss of parents (which contributes to separation anxiety) and fear of strangers. Some toddlers may be very slow to warm up to people they do not know. The nurse caring for a toddler in the outpatient or hospital setting should take the time to establish a relationship with the toddler in order to allay the toddler's fears. Toddlers may be afraid of loud noises and large or unfamiliar animals. Going to sleep may be a scary time for toddlers as they may be afraid of the dark. A nightlight in the toddler's room may be very helpful. (Kyle 104) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Moral and Spiritual Development

During the toddler years, children may feel comfort from the routine of praying, but they do not understand religious beliefs because of their limited cognitive abilities. Reading simple Bible stories can lay a foundation for later religious teachings. Kohlberg's (1984) description of moral development places the older toddler in the preconventional level. The toddler is only just beginning to learn right from wrong and does not understand the larger concept of morality. The toddler will base his or her actions on the avoidance of punishment and the attainment of pleasure. Older toddlers begin to feel empathy for others. (Kyle 104) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Musculoskeletal system

During toddlerhood, the bones increase in length and the muscles mature and become stronger. The abdominal musculature is weak in early toddlerhood, resulting in a pot-bellied appearance. The toddler appears to have a swayback along with the potbelly. Around 3 years of age, the musculature strengthens and the abdomen is flatter in appearance. (Kyle 98) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Avoiding exposure to tobacco smoke

Environmental exposure to tobacco smoke has been associated with increased risk of respiratory disease and infection, decreased lung function, and increased incidence of middle ear effusion and recurrent otitis media. It may also hinder neurodevelopment and may be associated with behavior problems (Hwang, Hwang, Moon & Lee, 2012). Parents should avoid cigarette smoking entirely to best protect their children. Even smoking outside of the home is suboptimal because smoke lingers on parents' clothing and children who are often carried (such as younger toddlers) face more exposure. Counsel parents to stop smoking (optimal), but if they continue smoking never to smoke inside the home or car with children present. (Kyle 108-109) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Psychosocial development

Erikson defines the toddler period as a time of autonomy versus shame and doubt. It is a time of exerting independence. Since the toddler developed a sense of trust in infancy, he or she is ready to give up dependence and to assert his or her sense of control and autonomy (Erikson, 1963). The toddler is struggling for self-mastery, to learn to do for himself or herself what others have been doing for him or her. Toddlers often experience ambivalence about the move from dependence to autonomy, resulting in emotional lability. The toddler may quickly change from happy and pleasant to crying and screaming. Exertion of independence also results in the toddler's favorite response "no." The toddler will often answer "no" even when he or she really means "yes." This negativism—always saying "no"—is a normal part of healthy development and is occurring as a result of the toddler's attempt to assert his or her independence. Table 4.1 gives further information related to developing a sense of autonomy. (Kyle 98) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Temper tantrums

Even children who displayed an easygoing personality as infants may lose their temper frequently during the toddler years (Fig. 4.14). A toddler who was more intense as an infant may have more temper tantrums. Temper tantrums are a natural result of the frustration that toddlers experience. Toddlers are eager to explore new things, but their efforts are often thwarted (usually for safety reasons). Toddlers do not behave badly on purpose. They need time and maturity to learn the rules and regulations. Some of their frustration may come from lack of language skills to express themselves. Toddlers are just starting to learn how to verbalize feelings and to use alternative actions rather than just "pitching a fit." The temper tantrum may be manifested as a screaming and crying fit or a full-blown episode in which the toddler throws himself or herself on the floor kicking, screaming, and pounding, perhaps even holding the breath. Fatigue or hunger may limit the toddler's coping abilities and promote negative behavior and temper tantrums (Lyness, 2013). (Kyle 118) Although tantrums are annoying to parents and caregivers, they are a normal part of the toddler's quest for independence. As toddlers mature, they become better able to express themselves and to understand their environment. Parents need to learn their toddler's behavioral cues in order to limit activity that is frustrating. When the parent notes the beginnings of frustration, a friendly warning might be given. Intervening early with an activity change might prevent a tantrum. Use distraction, refocusing, or removal from the situation. When a temper tantrum does occur, the best course of action is to ignore the behavior and ensure that the child is safe during the tantrum. Physical punishment will probably just prolong the tantrum and in fact produce more intense negative behavior. If the tantrum occurs in public, it may be necessary for the parent to immobilize the child with a big bear hug and use a calm voice to soothe the toddler. It is very important for parents to model self-control. Since toddlers' tantrums most often result from frustration, the role-modeled behavior of self-control helps to teach toddlers to control their temper when they can't get what they want (Lyness, 2013). (Kyle 118-119) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Thumb sucking and pacifiers

Infants bring their hands to their mouths and begin thumb sucking as a form of self-soothing (Sears & Sears, 2015c). This habit may continue into the toddler years and beyond. The pacifier is used for the same reason. Toddlers may calm themselves in a stressful situation by thumb sucking or sucking on a pacifier. Opinions about thumb and finger sucking and pacifier use are significantly affected by family history and culture. For most children there is no need to worry about a sucking habit until it is time for the permanent teeth to erupt. Prolonged and frequent sucking in the withdrawn child is more likely to yield changes to the tooth and jaw structure than sucking that is primarily used for self-soothing. Parents must sort through their own feelings about thumb sucking and pacifier use and then decide how they want to handle the habit. To ensure safety with pacifier use: Use only one-piece pacifiers. Replace worn pacifiers with new ones. Never tie a pacifier around a toddler's neck. Parents may want to limit thumb sucking and pacifier use to bedtime, in the car, and in stressful situations. The parent should calmly discuss these limits with the toddler and then remain consistent about enforcing them (Sears & Sears, 2015a, 2015c). (Kyle 119) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Sibling rivalry

Many families have subsequent children when their first child is a toddler. The toddler has been accustomed to being the baby and receiving a great deal of attention, both at home and with the extended family. Since toddlers are normally egocentric, bringing a new baby into the home may be quite disruptive. To minimize issues with sibling rivalry, parents should attempt to keep the toddler's routine as close to normal as possible. Spend individual time with the toddler on a daily basis. Involve the toddler in the care of the baby. The toddler is capable of fetching a diaper or T-shirt, entertaining the baby with a toy, or helping sing a song to calm the baby (Hirsch, 2013). "Helping" the parent care for the baby gives the toddler a sense of importance (Fig. 4.15). The toddler will need significant support while holding the baby. (Kyle 119) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Negativism

Negativism is common in the toddler period (Brazelton & Sparrow, 2006). As the toddler separates from the parent, recognizes his or her own individuality, and exerts autonomy, negativism abounds. Parents should understand that this negativism is a normal developmental occurrence and not necessarily deliberate defiance (though that also occurs). Avoid asking yes-or-no questions, as the toddler's usual response will be "no," whether he or she means it or not. Offering the child simple choices will give the toddler a sense of control. The parent should not ask the toddler if he or she "wants" to do something, if there is actually no choice. "Do you want to use the red cup or the blue cup?" is more appropriate than "Do you want your milk now?" When it is time to go outside, don't ask, "Do you want to put your shoes on?" Instead, state in a matter-of-fact tone that shoes must be worn outside, and give the toddler a choice of type of shoe or color of socks. If the child continues with negative answers, then the parent should remain calm and make the decision for the child. (Kyle 118) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Advancing solid foods

Parents should offer three full meals and two snacks daily. Portion sizes for toddlers are about one-quarter the size of adult portions. Large portions of a new or different food on the toddler's plate may intimidate the toddler. Normal toddler behaviors of mouthing, handling, tasting, extruding the food from the mouth, and then resampling the food often occur. These behaviors are distasteful to some parents but are a normal part of toddler development. Parents need to understand and tolerate these behaviors rather than scolding the toddler for them (Brazelton & Sparrow, 2006). Toddlers are often afraid to try new things anyway, so the parent or caregiver should be flexible with the toddler's acceptance or rejection of new foods. If the toddler refuses healthy food choices at meal or snack time, parents should not substitute high-fat, high-sugar, processed food just to make sure that the child eats something (Stettler, et al., 2011). This sets the stage for future power struggles. The parent decides which foods will be served or offered. The toddler decides how much will be eaten. The toddler self-regulates the amount of food needed to sustain and allow further growth and development. The toddler may not eat well every day but generally, over the course of several days, will consume the foods he or she needs (Zero to Three, 2014b). Foods should be served near room temperature. Some of the food on the plate should be soft and moist. Food should always be cut into bite-size pieces. Teaching Guidelines 4.2 gives recommendations on ways to prevent choking. (Kyle 112) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Promoting healthy growth and development

Parents who give their toddler love and respect regardless of the child's gender, behavior, or capabilities are helping to lay the foundation for self-esteem. Self-esteem is also built through familiarity with the daily routine. Routine and ritual help toddlers develop a conscience. Making expectations known through everyday routines helps to avoid confrontations. If the toddler knows the routine, he or she knows what to expect and how he or she is expected to act. When routine and limits are absent, the toddler develops feelings of uncertainty and anxiety. Limit setting (and remaining consistent with those limits) helps toddlers master their behavior, develop self-esteem, and become successful participants in the family. Children then are able to learn about cooperation throughout the predictable flow of daily life. Nurses need to be aware of normal developmental expectations in order to determine whether the toddler is progressing appropriately. Table 4.4 lists potential signs of developmental delay. Any toddler with one or more of these concerns should be referred for further developmental evaluation. (Kyle 105-106) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Regression

Some toddlers experience regression during a stressful event (e.g., the birth of a sibling, hospitalization). Stress in a toddler's life affects his or her ability to master new developmental tasks. During regression, the toddler may want to go back to an earlier stage. He or she may desire a bottle or pacifier forgotten long ago. The toddler may stop displaying previously achieved language or motor skills. A significant stress in the toddler's life may also disrupt the toilet teaching process (toilet teaching may not be achieved near the time a sibling is born). When regression occurs, parents should ignore the regressive behavior and offer praise for age-appropriate behavior or attainment of skills (Hirsch, 2013). (Kyle 119) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Promoting Language Development

Talking and singing to the toddler during routine activities such as feeding and dressing provides an environment that encourages conversation. Frequent, repetitive naming helps the toddler learn appropriate words for objects. The parent or caregiver should be attentive to what the toddler is saying as well as to his or her moods. Using clarification validates the toddler's emotions and ideas. Parents should listen to and answer the toddler's questions. They should sit down quietly with the toddler and gently repeat what the toddler is saying. Encouragement and elaboration convey confidence and interest to the toddler. The toddler needs time to complete his or her thoughts without being interrupted or rushed because he or she is just starting to be able to make the connections necessary to transfer thoughts and feelings into language. (Kyle 106-107) Parents should not overreact to the child's use of the word "no." They can give the toddler opportunities to use the word "no" appropriately by asking silly questions such as, "Can a cat drive a car?" or "Is a banana purple?" When promoting language development, the parent or primary caregiver should teach the toddler appropriate words for body parts and objects and should help the toddler choose appropriate words to label feelings and emotions. Toddlers' receptive language and interpretation of body language and subtle signs far surpass their expressive language, especially at a younger age (Feigelman, 2011b; Goldson & Reynolds, 2014). Parents should avoid discussing scary or serious topics in the presence of the toddler, since the toddler is very adept at reading emotions. If the parents speak a foreign language in addition to English, both languages should be used in the home. (Kyle 107) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Temperament

Temperament is the biologic basis for personality. It is our emotional and motivational core, around which the personality develops over time (Child Development Institute, 2015). Temperament affects how the toddler interacts with the environment. The easygoing toddler may adapt more easily and not mind changes in routine as much as other toddlers. The easygoing toddler usually sleeps and eats well and has more predictable and regular behaviors. However, the toddler may still express frustration by having a temper tantrum. The "difficult" toddler is more likely to have intense reactions, negative or positive, with temper tantrums being more likely, more frequent, and more intense than in other toddlers. The structure and routine that toddlers need to feel secure are essential for the difficult toddler; otherwise, the child feels insecure and as a result is more likely to behave inappropriately. The difficult toddler is also the most active of the three temperament types. The slow-to-warm-up toddler is more of a loner and may be very shy. He or she may experience more difficulty with separation anxiety. The behavior of the slow-to-warm-up toddler is more passive; the toddler may be very watchful and withdrawn and may take longer to mature. Changes in routine usually do not result in as much upset, since the toddler's natural reaction is one of passivity (Brazelton & Sparrow, 2006). Based on the toddler's temperament, make suggestions to the parents for interacting with the toddler in various situations. For example, to avoid temper tantrums in the difficult toddler, suggest that the parent should be especially diligent about maintaining structure and routine as well as avoiding tantrum triggers such as fatigue and hunger. Explain to parents that they may need to exercise additional patience with new activities to which the slow-to-warm-up toddler may need extra time becoming accustomed. (Kyle 104) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Promoting healthy sleep and rest

The 18-month-old requires 13.5 hours of sleep per day, the 24-month-old 13 hours, and the 3-year-old 12 hours (Feigelman, 2011a, 2011b). A typical toddler should sleep through the night and take one daytime nap. Most children discontinue daytime napping at around 3 years of age. The toddler who slept in a crib as an infant will need to move to a youth or toddler bed or even a full-size bed usually sometime in the toddler period. When the crib becomes unsafe (i.e., when the toddler becomes physically capable of climbing over the rails), then he or she must make the transition to a bed. Consistent bedtime rituals help the toddler prepare for sleep. Choose a bedtime and stick to it as much as possible. The nightly routine might include a bath followed by reading a story. The routine should be a calm period with minimal outside distractions. Toddlers often require a security item to help them get to sleep. Older toddlers may be afraid of the dark, so a nightlight is often helpful. Night waking is a problem for some toddlers. This may occur as a result of change in routine or as a desire for nighttime attention. Attention during night waking should be minimized so that the toddler receives no reward for being awake at night. The book Solve Your Child's Sleep Problems, by Dr. Richard Ferber (2006, New York: Fireside Publishing), is an excellent resource for the family with a toddler who resists bedtime or is a persistent night waker. For some toddlers, night waking is caused by nightmares. As the imagination and capacity for make-believe grow, the toddler may not be able to distinguish between reality and pretend. The parent should hold and comfort the toddler after a nightmare. Limiting television viewing (especially shortly before bedtime) may be helpful in limiting nightmares. Some families practice "co-sleeping" (when children sleep in the parents' bed). Although some professionals believe that co-sleeping may interfere with the toddler's struggle for independence, this theory has not been proven. The nurse should support the family's choice for sleep arrangements unless the co-sleeping is unsafe either physically or psychologically (SafeBedSharing.org, 2015). Refer to http://www.safebedsharing.org for bed-sharing safety guidelines. (Kyle 114) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Choosing a preschool

The older toddler may benefit from the structure and socialization provided by attending preschool. Attending preschool will help the toddler become more mature and independent and give the toddler a different source for a sense of accomplishment. At this age, toddlers need supervised play with some direction that fosters their cognitive development. A strict curriculum is not necessary in this age group. When choosing a preschool, the parent or caregiver should look for an environment that has the following qualities: Goals and an overall philosophy with which the parents agree (promotion of independence and self-confidence through structured and free play) Teachers and assistants trained in early childhood development as well as child cardiopulmonary resuscitation (CPR) Small class sizes and an adult-to-child ratio with which the parent feels comfortable Disciplinary procedures consistent with the parents' values Parents can visit at any time School is childproofed inside and out Appropriate hygiene procedures, including prohibiting sick children from attending Teach the parents how to ease the toddler's transition to attending preschool. Encourage parents to talk about going to preschool and visit the school a couple of times. On the first day, parents should calmly and in a matter-of-fact tone tell the toddler that they will return to pick him or her up. If the toddler expresses separation anxiety, the parent should remain calm and follow through with the plan for school attendance. After a few days of attendance, the toddler will be accustomed to the new routine and crying when parting from the parent should be minimal. (Kyle 108) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Preventing injury

The toddler is able to open drawers and doors, unlock deadbolts, and climb anywhere he or she wants to go. Toddlers have a limited concept of body boundaries and essentially no fear of danger. Toddlers may fall from any height to which they can climb (e.g., play structures, tables, counters). They may also fall from wheeled toys such as tricycles. As toddlers gain additional height and hand dexterity they are able to reach potentially dangerous items on the counter or stove, leading to an accidental ingestion, burn, or cut. The AAP advises against having guns in homes with children. If a gun is kept in the home it should be stored unloaded and locked away (AAP, 2015b). To prevent injury in the home, stress the following to parents: Never leave a toddler unsupervised out of doors. Lock doors to dangerous rooms. Install safety gates at the top and bottom of staircases. Ensure that window locks are operable; if windows are left opened, then secure all window screens. Keep pot handles on the stove turned inward, out of an inquisitive toddler's reach. Teach the toddler to avoid the oven, stove, and iron. Keep electrical equipment, cords, and matches out of reach. Remove firearms from the home, or keep them in a locked cabinet out of the toddler's reach. Always require the child to wear a helmet approved by the Consumer Products Safety Commission (CPSC) when riding a wheeled toy. This starts the habit of helmet wearing early, so it can be more easily carried over to the bicycle-riding years of the future. Begin teaching the toddler about watching for cars when crossing the street, but always carry or hold the hand of the toddler when crossing the street. Teach the toddler to avoid unknown animals (AAP, 2015c, 2015d). (Kyle 109) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Nurses Role in Growth & Development

The toddler's growth and development affects his or her everyday life as well as the family's. Though some toddlers may grow more quickly or reach developmental milestones sooner than others, growth and development remains orderly and sequential. Health care visits throughout toddlerhood continue to focus on growth and development. The nurse must have a good understanding of the changes that occur during the toddler years in order to provide appropriate anticipatory guidance and support to the family. When the toddler is hospitalized, growth and development may be altered. The toddler's primary task is establishing autonomy, and the toddler's focus is mobility and language development. Hospitalization removes most opportunities for the toddler to learn through exploration of the environment. Isolation for contagious illness further constrains the toddler's ability to find some control over the environment. The nurse caring for the hospitalized toddler must use knowledge of normal growth and development to be successful in interactions with the toddler, promote continued development, and recognize delays (see Chapter 11) (Fig. 4.6). (Kyle 105) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Organ system maturation

Though not as pronounced as the changes occurring during infancy, the toddler's organ systems continue to grow and mature in their functioning. Significant functional changes occur within the neurologic, gastrointestinal, and genitourinary systems. The respiratory and cardiovascular systems undergo changes as well. (Kyle 97) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Promoting self feeding and healthy eating habits

Toddlers most often eat with their fingers, but they do need to learn to use utensils properly. The following are suggestions for parents: Use a child-sized spoon and fork with dull tines. Seat the toddler in a high chair or at a comfortable height in a secure chair. The toddler should have his or her feet supported rather than dangling (Fig. 4.11). Never leave the toddler unattended while eating. Minimize distractions during mealtime. Serve food to the toddler along with the other members of the family (Gavin, 2014b). Promoting Healthy Eating Habits Since the toddler's rate of growth has slowed somewhat compared to that in infancy, the toddler requires less caloric intake for his or her size compared to the infant. This results in physiologic anorexia: toddlers simply do not require as much food intake for their size as they did in infancy. The toddler will also exhibit food jags. During a food jag, the toddler may prefer only one particular food for several days, then not want it for weeks. Again, it is important for the parent to continue to offer healthy food choices during a food jag and not give in by allowing the toddler to eat junk food (Gavin, 2014b). (Kyle 112) The normal developmental issue of testing limits will also occur for the toddler at mealtime. Since toddlers still have limited ability to express their emotions with words, they use nonverbal behaviors to do so. While eating, the toddler may dislike the taste of a particular food or experience a feeling of fullness but will communicate that feeling by screaming or throwing food. When the child exhibits these behaviors, the parent must remain calm and remove the toddler from the situation. Meals should be eaten in a calm and pleasant environment. Parents should serve as role models for appropriate eating habits, but toddlers may also be willing to try more foods if they are exposed to other children who eat those foods. Praise the child for trying a new food, and never punish the toddler for refusing to try something new. A new food may need to be offered many times in a row before the toddler chooses to try it. Parents should be sure to include foods the child is familiar with and likes to eat at the same meal that the new food is being introduced (Zero to Three, 2014b). Teaching Guidelines 4.3 lists alternative foods that meet nutritional needs and a list of books for parents of the picky eater. (Kyle 113) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Sensory development

Toddlers use all of their senses to explore the world around them. Toddlers examine new items by feeling them, looking at them, shaking them to hear what sound they make, smelling them, and placing them in their mouths. Toddler vision continues to progress and should be 20/50 to 20/40 in both eyes. Depth perception also continues to mature. Hearing should be at the adult level, as infants are ordinarily born with hearing intact. The sense of smell continues to mature, and toddlers may comment if they do not care for the scent of something. Though taste discrimination is not completely developed, toddlers may exhibit preferences for certain flavors of foods. The toddler is more likely to try a new food if its appearance or smell is familiar. Lack of complete taste discrimination places the toddler at risk of accidental ingestion. (Kyle 101) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.