PEDS/ TODDLER CHAPTER 26

PREVENTING POISONING ºAs 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. ºTheir 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. ºBox 26.2 lists most potentially dangerous ingested poisons. Discuss poison prevention in the home at each well-child visit (see Healthy People 2020). The AAP (2015c) recommends that potentially poisonous substances (e.g., medications, cleaners, hair care products, car care products) be stored out of the toddler's reach, out of the toddler's sight, and in a childproof, locked cabinet.

BOX 26.2 MOST DANGEROUS POTENTIAL POISONS ºMedicines (especially iron) ºCleaning products ºAntifreeze, windshield washer solution ºAlcohol ºPesticides ºGasoline, kerosene, lamp oil, furniture polish ºWild mushrooms

SAFETY IN THE WATER º Parents who want to enroll a toddler in a swimming class should be aware that a water safety skills class would be most appropriate. ºHowever, even toddlers who have completed a swimming program still need constant supervision in the water (Safe Kids, 2016b). Box 26.3 gives recommendations for the prevention of drowning.

BOX 26.3 PREVENTING DROWNING ºPools should be fenced with locked gates or screened with locked doors. ºInterior doors should be kept locked. ºYoung children should never be left unattended in or near water. ºWater wings or "floaties" are not a substitute for adult supervision or for personal flotation devices. ºUS Coast Guard-approved life preservers or personal flotation devices should be available when a young child is in or near a body of water. ºParents and caregivers should be trained in child cardiopulmonary resuscitation (CPR).

ºDiscipline 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. ºOffering realistic choices helps give the toddler a sense of mastery. Rules should be simple and limited in number. ºMaintaining the toddler's schedule of meals and rest/sleep will help to prevent conflicts that occur as a result of hunger or fatigue. ºToddlers should not be made to share, as this is a concept they do not understand. ºParents should encourage simple activities enjoyed by the children involved and avoid confrontation over toys. ºParents should offer toddlers appropriate choices to help them develop autonomy, but should not offer a choice when none exists.

BOX 26.5 NEGATIVE IMPACT OF PHYSICAL PUNISHMENT ºSpanking is less effective than time-out or other discipline measures to reduce undesired behavior in children. ºThe toddler younger than 18 months of age: Is not capable of making the appropriate connections between spanking and the undesired behavior ºIs at increased risk for physical injury from spanking than older children

CULTURAL INFLUENCES ON GROWTH & DEVELOPMENT ºHomelessness 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. ºAppropriate 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. ºIndividual 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. ºCulture 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

Barriers to Cultural Competence ºIllness is culturally shaped in the sense that how we perceive, experience, and cope with disease is based upon our explanations of sickness. ºAwareness of how this might be of influence—instead of mere knowledge about the cultural practices or beliefs of specific ethnic groups—and an appreciation of this factor helps nurses deal effectively with cultural issues ºWhen a health care provider lacks knowledge of a client's cultural practices and beliefs or when the provider's beliefs differ from those of the client, the provider may be unprepared to respond when the client makes unexpected health care decisions. ºSystem-related barriers can occur if agencies that have not been designed for cultural diversity want all clients to conform to the established rules and regulations and attempt to fit everyone into the same mold.

Emotional and Social Development of the Toddler • Focus -Separation - Individuation- ºSeeing oneself as separate from the parent • Individuation Forming a sense of self and learning to control ones environment lead to emotional lability. • Egocentrism (Focus on self)- As this need to feel in control of his or her world emerges. -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. ºAs toddlers identify the boundaries between themselves and the parent or primary caregiver, they learn to negotiate a balance between attachment and independence. ºToddlers 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

Emotional and Social Development of the Toddler ºPower 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). ºMany toddlers rely on a security item (blanket, doll, or bear) to comfort themselves in stressful situations (Fig. 26.5). 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.

SEPARATION ANXIETY ºAs toddlers become increasingly skilled at mobility, they realize that if they have the capability of leaving, then so does the parent. ºAs 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). ºPower struggles may escalate and distress at separating from the parent may increase. ºAgain, a predictable routine with appropriate limit setting may help toddlers to feel safer and more secure during this period. ºFrom the age of 24 to 36 months, separation anxiety again eases. ºThe 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.

FEARS ºCommon fears of toddlers include loss of parents (which contributes to separation anxiety) and fear of strangers. ºSome toddlers may be very slow to warm up to people they do not know. ºThe 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. ºToddlers may be afraid of loud noises and large or unfamiliar animals. ºGoing 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.

Teaching Strategies to Minimize Issues with Sibling Rivalry ºAttempt to keep the toddler's routine as close to normal as possible ºSpend individual time with the toddler on a daily basis ºInvolve the toddler in the care of the baby

Focus of Discipline for the Toddler ºLimit setting ºNegotiation ºTechniques to assist the toddler to learn problem solving ºThe toddler needs firm, gentle guidance to learn what the expectations are and how to meet them. ºThe 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. ºHaving realistic expectations of what the toddler is capable of learning and understanding can help the parent in the disciplinary process.

Cardiovascular system Heart rate decreases; blood pressure increases ºBlood vessels are close to the skin surface and so are compressed easily when palpated. Gastrointestinal system Stomach increases in size (3 reg. meals a day); ;Pepsin production matures by 2 years of age. ; small intestine grows in length; stool passage decreases. ºThe color of the stool may change (yellow, orange, brown, or green) depending on the toddler's diet. ºSince the toddler's intestines remain somewhat immature, the toddler often passes whole pieces of difficult-to-digest food such as corn kernels. ºBowel control is generally achieved by the end of the toddler period.

Genitourinary system Bladder and kidney reach adult function by 16 to 24 months; bladder capacity increases (toddler retains urine); º urine output should be about 1 mL/kg/hour º urethra remains short- susceptible for UTI Musculoskeletal system Bones increase in length; muscle matures & become stronger; º sway back and pot belly abdominal musculature) appear due to weak muscles until 3 years old. ºAround 3 years of age, the musculature strengthens and the abdomen is flatter in appearance.

Role of Parent ºTalk and sing to child to encourage conversation and promote language development ºRead to toddler every day ºParental role modeling of appropriate behavior, especially related to dealing with frustration, is beneficial to toddlers. ºParents play an important role in toddler development, not only by providing a loving environment but also by role modeling appropriate behavior in most areas of daily life.

KEY CONCEPTS ºThe toddler's organ systems are continuing to mature, and growth slows during this period as compared with infancy. ºThe psychosocial task of the toddler years is to attain a sense of autonomy and to experience separation and individuation. ºCognitive development in toddlerhood progresses from sensorimotor in nature to preoperational. ºThe toddler refines gross motor skills after learning to walk and builds fine motor skills through the use of utensils and various manipulative toys.

KEY CONCEPTS ºThe toddler progresses from limited expressive language capabilities to a vocabulary of 900 words by age 3 years. ºToddlers use all of their senses to explore and learn about their environment. ºVisual acuity progresses to at least 20/50 in the toddler period. ºNegativism abounds in toddlers as they attempt to exert their independence. ºVery ritualistic, toddlers feel safer and more secure when clear limits are enforced and a structured routine is followed. ºThe toddler is starting to learn right from wrong and bases actions on punishment avoidance.

KEY CONCEPTS ºToddler development may be promoted through active gross motor play, books, music, and block building. ºSafety is a primary concern in the toddler years as the child is more mobile, very curious, and experimenting with autonomy. ºPoisoning in the toddler period may be prevented through proper storage of medications and other potentially poisonous substances and appropriate supervision. ºConsistent bedtime rituals help ease the toddler's transition to sleep. ºAll primary teeth are erupted by 30 months of age and may be kept healthy with appropriate tooth brushing and fluoride supplementation.

Motor Skill Development (Toddler) Gross motor skills Include running, climbing, jumping, pushing or pulling a toy, throwing a ball, and pedaling a tricycle ºAs 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. ºThe 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 ºOften, 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. ºBy 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

Motor Skill Development (Toddler) Fine motor skills Progress from holding and pinching to the ability to manage utensils, hold a crayon, string a bead, and use a computer ºFine motor skills in the toddler period are improved and perfected. ºHolding utensils requires some control and agility, but even more is needed for buttoning and zipping. ºAdequate 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.

Toilet Teaching ºAfter 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. ºToddlers should never be punished for bowel or bladder "accidents." ºWith 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. ºBoys 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. ºThe 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). ºIf 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.

NEGATIVISM ºNegativism 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. ºParents should understand that this negativism is a normal developmental occurrence and not necessarily deliberate defiance (though that also occurs). ºAvoid asking yes-or-no questions, as the toddler's usual response will be "no," whether he or she means it or not. ºOffering the child simple choices will give the toddler a sense of control.

Physical Growth of the Toddler 1 TO 3 YEARS OLD ºHeight and weight increase steadily in spurts at a slower rate than the infant º spurts rather than linear ºGenerally reach half adult height by age 2 ºAverage weight gain is 3 (1.36) to 5 (2.27) lb per year ºHeight increases an average of 3 (7.62cm) in per year ºFontanels close by 18 months ºHead size more proportional to body by age 3 ºHead 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. *Learn by trial and error = 12- 18months Cage- top cribs if admitted

Organ System Maturation Neurologic system Brain reaches about 90% of size by age 2 ºMyelination 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 ºRapid increase in language skills is evidence of continued progression of cognitive development. Respiratory system Alveoli increase in number until age 7; trachea and airways small compared to adult ºThe tongue is relatively large in comparison to the size of the mouth. ºTonsils and adenoids are large and the Eustachian tubes are relatively short and straight.

PREVENTING INJURY To prevent injury in the home, stress the following to parents: ºNever leave a toddler unsupervised out of doors. ºLock doors to dangerous rooms. ºInstall safety gates at the top and bottom of staircases. ºEnsure that window locks are operable; if windows are left opened, then secure all window screens. ºKeep pot handles on the stove turned inward, out of an inquisitive toddler's reach. ºTeach the toddler to avoid the oven, stove, and iron. ºKeep electrical equipment, cords, and matches out of reach.

PREVENTING INJURY To prevent injury in the home, stress the following to parents: ºRemove firearms from the home, or keep them in a locked cabinet out of the toddler's reach. ºAlways 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. ºBegin 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. ºTeach the toddler to avoid unknown animals

SAFETY IN THE HOME ºAvoiding exposure to tobacco smoke, preventing injury, and preventing poisoning. ºAVOIDING 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.

PREVENTING INJURY ºThe toddler is able to open drawers and doors, unlock deadbolts, and climb anywhere he or she wants to go. ºToddlers have a limited concept of body boundaries and essentially no fear of danger. ºToddlers 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. ºAs 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. ºThe 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

PROMOTING HEALTHY TEETH AND GUMS º30 months toddler has full set of primary teeth ºParents may not be aware of the importance of preventing cavities in primary teeth since they will eventually be replaced by the permanent teeth. ºPoor 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.). ºCleaning 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. 26.12). ºWeaning 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.

PROMOTING HEALTHY TEETH AND GUMS º1st dental apt @ age 1. ºEating should be limited to meal and snack times, as "grazing" throughout the day exposes the teeth to food throughout the day. ºCarbohydrate-containing foods combined with oral bacteria create a decreased oral pH level that is optimal for the development of dental caries (cavities) ºPublic water fluoridation is a public health initiative that ensures that most children receive adequate fluoride intake to prevent dental caries. ºTable 26.5 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. ºExcess fluoride ingestion should be avoided, as it contributes to the development of fluorosis (mottling of the enamel).

Promoting Safety for the Toddler ºProvide a childproof environment ºUse a safe car seat in back of car ºProvide a safe home environment ºAvoid exposure to tobacco smoke ºPrevent injury ºPrevent poisoning PROMOTING SAFETY; SAFETY IN THE CAR ºThe 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. ºAt a minimum, toddlers should be in a rear-facing car seat with harness straps and a clip until 2 years of age ºAfter 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.

PROMOTING SAFETY; SAFETY IN THE CAR ºIf 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. ºThe 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. 26.10). ºIn 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

Physical punishment: ºMay lead to a pro-violence attitude ºMay create resentment in the toddler ºIs a poor model for learning effective problem solving ºMay be correlated with antisocial and criminal behavior later in life ºLeads to increased aggression in preschoolers, school-age children, and adults ºWhen used frequently, may weaken the parent-child relationship Physical punishment: ºChildhood corporal punishment increases the probability of depression and substance abuse in adulthood. ºSpanking may lead to more severe forms of punishment and to actual child abuse and maltreatment. ºThe more frequently children are hit or spanked, the more likely they are to hit their own children and to be involved in spouse abuse as adults.

Physical punishment: ºPositive reinforcement should be used as much as possible. º"Catching" a child being good helps to reinforce appropriate or desirable behaviors. ºWhen the toddler is displaying appropriate behavior, the parent should reward the child consistently with praise and physical affection. º "Time-out" can be used effectively at around 2.5 to 3 years of age (refer to Chapter 27 for details). "Extinction" is a particularly useful technique with 2- and 3-year-olds. ºExtinction 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).

SIBLING RIVALRY ºMany 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. ºSince toddlers are normally egocentric, bringing a new baby into the home may be quite disruptive. ºTo 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. ºThe 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). º"Helping" the parent care for the baby gives the toddler a sense of importance (Fig. 26.15). The toddler will need significant support while holding the baby

REGRESSION ºSome toddlers experience regression during a stressful event (e.g., the birth of a sibling, hospitalization). ºStress in a toddler's life affects his or her ability to master new developmental tasks. ºDuring regression, the toddler may want to go back to an earlier stage. ºHe 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). ºWhen regression occurs, parents should ignore the regressive behavior and offer praise for age-appropriate behavior or attainment of skills

Encourage all families to take the following safety measures: ºStore all substances in original containers only. ºNever store any liquid other than soda in a soda pop bottle. ºDo not allow toddlers access to baby powder, lotion, cream, or other toddler hygiene products. ºEnsure all medications have child-safety caps. ºDo not leave within the toddler's reach medications such as lozenges or samples that are not packaged in safety bottles. ºBe very careful with medications that are provided in transdermal patch form. ºDo not refer to medicines as candy, as the toddler may mistake pills for candy and ingest them. ºDo not expose toddlers to hazardous vapors such as paints, cleaners, tobacco smoke, and especially street drugs such as crack and marijuana. ºKeep "button" batteries secured and away from a toddler's reach. ºKeep 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, 2015c).

SAFETY IN THE WATER ºDrowning 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, 2015). ºDrowning 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. ºToddlers' 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. ºToddlers 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.

Common Developmental Concerns of the Toddler ºToilet teaching ºNegativism ºTemper tantrums ºThumb sucking and pacifiers ºSibling rivalry ºAggression Signs a Toddler Is Ready for Toilet Teaching ºRegular bowel movement ºExpresses knowledge of 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

Signs a Toddler Is Ready for Toilet Teaching ºThe diaper is not always wet (this indicates the ability to hold the urine for a period of time). ºThe toddler is willing to follow instructions ºThe toddler walks well alone and can pull down pants ºThe toddler follows caregiver to bathroom ºThe toddler climbs onto potty chair or toilet

NEGATIVISM ºThe parent should not ask the toddler if he or she "wants" to do something, if there is actually no choice. º"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. ºIf the child continues with negative answers, then the parent should remain calm and make the decision for the child.

TEMPER TANTRUMS ºA toddler who was more intense as an infant may have more temper tantrums. ºTemper tantrums are a natural result of the frustration that toddlers experience. ºToddlers are eager to explore new things, but their efforts are often thwarted (usually for safety reasons). ºToddlers do not behave badly on purpose. They need time and maturity to learn the rules and regulations. ºSome of their frustration may come from lack of language skills to express themselves. ºToddlers are just starting to learn how to verbalize feelings and to use alternative actions rather than just "pitching a fit."

TEMPER TANTRUMS ºThe 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. ºFatigue or hunger may limit the toddler's coping abilities and promote negative behavior and temper tantrums ºAlthough tantrums are annoying to parents and caregivers, they are a normal part of the toddler's quest for independence. ºAs toddlers mature, they become better able to express themselves and to understand their environment. ºParents 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. ºUse distraction, refocusing, or removal from the situation.

TEMPER TANTRUMS ºWhen 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. ºPhysical punishment will probably just prolong the tantrum and in fact produce more intense negative behavior. ºIf 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. ºIt 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

THE NURSE'S ROLE IN TODDLER GROWTH AND DEVELOPMENT ºThe 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. ºHealth 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.

THE NURSE'S ROLE IN TODDLER GROWTH AND DEVELOPMENT ºWhen 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. ºHospitalization 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. ºThe 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

THUMB SUCKING &PACIFIERS ºInfants bring their hands to their mouths and begin thumb sucking as a form of self-soothing (Sears & Sears, 2016c). ºThis 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. ºOpinions about thumb and finger sucking and pacifier use are significantly affected by family history and culture. ºFor most children there is no need to worry about a sucking habit until it is time for the permanent teeth to erupt. ºProlonged 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.

THUMB SUCKING &PACIFIERS ºParents 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: ºUse only one-piece pacifiers. ºReplace worn pacifiers with new ones. ºNever tie a pacifier around a toddler's neck. ºParents 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

Physical punishment: ºParents who want to extinguish an annoying (nondangerous) behavior should resolve to ignore it every time it occurs. ºWhen the child withholds the behavior or performs the opposite (appropriate) behavior, they should use compliments and praise. ºIt may be difficult to ignore a difficult behavior, but the results are well worth the effort. Teaching Guidelines 26.4 provides tips on avoiding power struggles and offering appropriate guidance to toddlers. Teaching Guideline 26.4 PROVIDING TODDLERS WITH GUIDANCE ºWhen giving the toddler instructions, tell the child what to do, NOT what not to do. This allows for a positive focus. If you must say "no," "don't," or "stop," then follow with a direction of what to do instead. ºOffer limited choices, when a choice is truly available. Say, "Do you want to wear your blue hat or your red hat?" NOT "Do you want to put on your hat?" This gives the toddler some, but not all, control.

Teaching Guideline 26.4 PROVIDING TODDLERS WITH GUIDANCE ºRole model appropriate communication, but don't feel like you have to speak nicely all the time. If the situation warrants, use a firm and even tone to get the point across. ºAvoid yelling. ºPay attention to the inflection in your voice. A statement or direction should not end in a questioning tone or with "Okay?" Be clear. ºStatements should sound like statements, and only questions should end in a questioning tone. ºWhen a toddler behaves aggressively, label the child's feelings calmly, but be firm and consistent with the expectation. For example, "I know you're mad at your friend, but it is not okay to hit."

Toilet Teaching ºParents should approach toilet teaching with a calm, positive, and nonthreatening manner. ºInitially 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. ºThe toddler will feel most comfortable with a toddler potty chair that sits on the floor (Fig. 26.13). 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. ºAfter 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. ºThe 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.

Toilet Teaching ºParents should always use gentle praise and no reproaches. ºUsually 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. ºIt may be many months before nighttime bladder control is achieved, and the toddler may still require a diaper at night. ºParents 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, 2015d).

Typical Behaviors of the Toddler ºMay rely on a security item ºBecomes aware of gender differences- They observe the differences between male and female body parts if they are exposed to them ºMay display aggressive behaviors- 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. -Offering limited choices is one way of allowing toddlers some control over their environment and helping them to establish a sense of mastery

Typical Behaviors of the Toddler ºAs the toddlers become more self-aware, they start to develop emotions of self-consciousness such as embarrassment and shame. ºMay show fear of loss of parents and of strangers ºBecomes more self-aware; does not have clear body boundaries- though they are beginning to make appropriate connections. ºFeces may be viewed as a part of the child, and the toddler may become upset at seeing it disappear in the toilet. ºSeparation anxiety may reoccur ºMay resist invasive procedures- The toddler will protect his or her body by resisting intrusive procedures such as temperature or blood pressure measurement.

Sleep and Dental Health Requirements for the Toddler 18-month-old: 13.5 hours of sleep per day 24-month-old: 13 hours of sleep per day 3-year-old: 12 hours of sleep per day ºA typical toddler should sleep through the night and take one daytime nap ºMost children discontinue daytime napping at around 3 years of age ºWhen 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. ºThe nightly routine might include a bath followed by reading a story º night light ºNight waking is a problem for some toddlers. This may occur as a result of change in routine or as a desire for nighttime attention. ºAttention during night waking should be minimized so that the toddler receives no reward for being awake at night. ºThe 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. ºFor some toddlers, night waking is caused by nightmares.

ºAs the imagination and capacity for make-believe grow, the toddler may not be able to distinguish between reality and pretend. ºThe parent should hold and comfort the toddler after a nightmare. ºLimiting television viewing (especially shortly before bedtime) may be helpful in limiting nightmares. ºSome families practice "co-sleeping" (when children sleep in the parents' bed). ºAlthough some professionals believe that co-sleeping may interfere with the toddler's struggle for independence, this theory has not been proven. ºThe nurse should support the family's choice for sleep arrangements unless the co-sleeping is unsafe either physically or psychologically

Speech Development (Toddler) ºReceptive language development: the ability to understand what is being said or asked is typically far more advanced than expressive language development (ability to communicate desires and feelings) ºIn 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 ºCommon occurrences ºEcholalia: 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. ºTelegraphic speech: º speech that contains only the essential words to get the point across; º common In the 3 year old. º. 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 ºEarly identification and referral of children with potential speech delays is critical.

ºIf a delay is identified, early intervention may increase the child's potential to acquire age-appropriate receptive and expressive language skills. ºChildren 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. 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 ºYoung children exposed to more than one language may experience simultaneous acquisition of both languages. The first word may be slightly delayed as compared with single language speakers, but still occurs within the normal range

ºCultural competence does not mean replacing one's own cultural identity with another, ignoring the variability within cultural groups, or even appreciating the cultures being served. ºInstead, nurses skilled at cultural competence show a respect for difference, an eagerness to learn, and a willingness to accept multiple views of the world. ºMuch of the process of developing cultural competence involves a reexamination of our values and the influence of these values on our beliefs, which affect our attitudes and actions. ºAt the core of both client centeredness and cultural competence is the importance of seeing the client as a unique person

ºIt is important for all nurses to incorporate the client's traditional healing and health practices with conventional medicine by asking such questions as, Do you have treatment preferences you would like me to include in your care plan? ºSome clients may prefer certain foods or drinks when they are ill. In addition, during fasting and religious seasons, diets may be different and need to be considered during the process of determining the appropriate course of treatment. ºSome may have a different idea of what caused the illness. Spirituality, culture, and experience may have a significant role in the client's understanding and treatment of the illness.

Promoting Growth and Development of the Toddler through Play ºPlay is the major socializing medium for toddlers. ºToddlers need 30 minutes of structured physical activity and 1 to 3 hours of unstructured physical activity per day. ºParents should limit television and encourage creative and physical play instead. ºToddlers engage in parallel play (playing alongside another child) instead of cooperative play. ºToddlers are egocentric and do not like to share. ºThe short attention span of toddlers will make them change toys frequently. ºToddlers do not need expensive toys.

ºThe best toys for toddlers are familiar household items, child-sized household items, blocks, cars, plastic figures, stuffed animals, dolls, doll beds, and carriages. ºManipulative toys with knobs and buttons that make things happen, shapes to insert into matching holes, puzzles, chalk, buckets and shovels, and floating toys are also recommended. ºAppropriate gross motor toys include gyms, tricycles, pull toys, and wagons.

PSYCHOSOCIAL ºErikson's theory focuses on achievement of autonomy and self-control/ shame and doubt. -. 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 -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.

ºThe 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.

ºThe toddler's intense push for autonomy can often test a parent's limits. The easygoing infant usually becomes more challenging in toddlerhood. ºThe 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. ºIn 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 ºSpanking 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

ºToddlers younger than 18 months of age should NEVER be spanked, as there is an increased possibility of physical injury in this age group. ºAlso, the infant/young toddler is not capable of linking the spanking with the undesired behavior ºNormal toddler development includes natural curiosity, and this curiosity often results in dangerous or problematic activities for the toddler (Lyness, 2013). ºToddlers have a difficult time learning the rules and, in general, do not behave badly intentionally. ºProviding 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.

Growth Theories ºFreud's theory focuses on the satisfaction and/or frustration of expelling feces (anal stage). COGNITIVE ºPiaget's theory focuses on development of the senses of the toddler. ºtoddlers move through the last two substages of the first stage of cognitive development, the sensorimotor stage, between 12 and 24 months of age. ºRather 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. ºPiaget 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.

ººThe 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 ºObjects are considered large or small, having a particular color or shape, or having a unique texture. ºThis 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 ºToddlers 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. 26.2). Human feelings and characteristics may also be attributed to objects (animism