Ch. 31 & 32- The Infant and Toddler

Promoting Optimal Growth and Development

-Biological Development:Proportional changes *5-7 ounces weight gain per week *Double birth weight by age 6 months *Triple birth weight by age 1 year *Height increases by 1 inch per month *Growth in "spurts" rather than gradual pattern *Height increases 50% by 1 year *Head Circumference still exceeds chest circumference *Posterior fontanel closes by 6-8 weeks *Anterior fontanel closes by 12-18 months

Spiritual Development

-Evolution of spirituality often parallels cognitive development -Family and environment influence a child's perception of the world Intuitive-projective phase is experienced -Fowler's faith construct -Spiritual routines can be comforting -Moral development: action is bad if they are punished for it

Development of Gender Identity

-Exploration of genitalia is common Genital fondling can occur Parental reaction should be accepting -Gender roles are understood by toddler Playing "house" -Gender identity is formed by age 3 years

Safe Pad

-Identify common pediatric injuries S: Suffocation, sleep position A: Asphyxia, animal bites F: Falls E: Electrical burns or burns P: Poisonings, ingestions A: Automobile safety D: Drowning

Emergency Treatment Poisoning

1. Assess the victim: • Initiate cardiorespiratory support if needed (circulation, airway, breathing). • Take vital signs; reevaluate routinely. • Evaluate for possibility of concomitant trauma or illness; treat prior to initiation of gastric decontamination. 2. Terminate exposure: • Empty mouth of pills, plant parts, or other material. • Flush any body surface (including the eyes) exposed to a toxin with large amounts of moderately warm water or saline. • Remove contaminated clothes, including socks, shoes, and jewelry. Ensure protection of rescuers and health care workers from exposure. • Bring victim of an inhalation poisoning into fresh air. 3. Identify the poison: • Question the victim and witnesses. • Look for environmental clues (empty container, nearby spill, odor on breath), and save all evidence of poison (container, vomitus, urine). • In absence of other evidence, be alert to signs and symptoms of potential poisoning in the absence of other evidence, including symptoms of ocular or dermal exposure. • Call the poison control center or other competent emergency facility for immediate advice regarding treatment. 4. Prevent poison absorption: • Place the child in a side-lying, sitting, or kneeling position with the head below the chest to prevent aspiration.

Piaget Cognitive Development

1. sensorimotor 2. pre-operational 3. concrete operational 4. formal operational 1-4 months eating is the most important for the infant

Language Development

1st communication is crying, and is more of a reflex that represents physiological needs. At 5 weeks infants start making small throaty sounds. At 2 months they start making single vowel sounds. 3-4 months the conscious n,k,g,p are added. 8 months they imitate sounds but do not describe meaning until 10-11 months. By 9-10 months of age they can comprehend the meaning of the word no.

Safety promotion and injury prevention

3 leading causes of deaths are from suffocation, drowning, and motor vehicle accidents. Rear facing car seat until 2 years of age or pass required height and weight. Must be in back seat because of the airbag.

Ingestion of Injurious Agents

90% occur in the home Home immediate treatment Call Poison Control Center Syrup of ipecac is not recommended in the home Emergency department management Gastric lavage (not recommended in all cases) Activated charcoal Antidotes Cathartics

apparent life-threatening event (ALTE)

A sudden event in infants under the age of 1 year, during which the infant experiences a combination of symptoms including apnea, change in color, change in muscle tone and coughing or gagging. Aborted or near miss SIDS.

The terrible twos

Ages 12 to 36 months. Intense period of environmental exploration. Temper tantrums/obstinacy/negatvisim.

Gross Motor Development: Standing, Walking

All children will not take first steps at the same age. Pediatric nurse should assess/ask if infant is pulling up to a standing position by the age of 11-12 months

Coping with Concerns Related to Normal Growth and Development

Alternative childcare arrangements Limit setting- time outs

head lag nursing alert

An infant who displays head lag at 6 months of age should have a developmental and neurologic evaluation.

hip dysplasia nursing alert

An infant who does not pull to a standing position by 11 to 12 months of age should be further evaluated for possible developmental dysplasia of the hi

Skin Disorders (Toddlers)

Arthropod bites and stings: remove stinger and observe for allergic reaction. Children should not approach a dog that is eating, sick, or injured and should never tease or surprise them. Most common animal bite is from dogs. Rinse round with saline and wash with mild soap then apply clean dressing. then seek medical care. Human bites- immediately seek medical attention. wash wound with soap and water and apply dressing.

Animism

Attributing lifelike qualities to inanimate objects Example: Child scolds stairs for making child fall down. Implication: Join child in the "scolding." Keep frightening objects out of view.

Drowning

Bath tub-NEVER leave infant unattended in tub or sink of water.Swimming pools, bird baths, decorative ponds of water, splash pads-Place fence around pools with gate lock that is out of child's reach. Supervise infants in water at ALL times; an infant may drown in as little as 2 inches of water. Swimming lessons are encouraged but are not foolproof for drowning if infant or child hits head on hard object and becomes unconscious as falling into the water.5-gal buckets-Keep 5-gal buckets empty of water and elevated out of child's reach.

Immunizations

Begin at birth. Flu shot at 6 months. Important for the prevention of communicable diseases. Atraumatic care- pacifier or mom breast feeding when the immunization is being administered. Fewer Reactions with IM injections than sub q. IM tissue is more vascular.

peroperational stage

Begins about age 2 and last until age 4. It is the transition between self-satisfying behavior and socialized relationships.

Dental Health

Begins with Maternal Dental Health Cleaning: Wipe with a clean damp cloth when primary teeth erupt. Fluoride at 6 months. Prevention of dental caries: no bottle propping, no milk in bed, no fruit juices.

Magical Thinking

Believing that thoughts are all-powerful and can cause events Examples: Child wishes someone died; then if the person dies, child feels at fault because of the "bad" thought that made the death happen. • Calling children "bad" because they did something wrong makes them feel as if they are bad. Implications: Clarify that thoughts do not make things happen and that the child is not responsible. • Use "I" rather than "you" messages to communicate thoughts, feelings, expectations, or beliefs without imposing blame or criticism. Emphasize that the act is bad, not the child.

Nutrition Second 6 months

Breastmilk or formula should continue to be the primary source of nutrition. Iron-fortified cereal is usually introduced first. Common sequence of introducing foods is shrined fruits followed by vegetables and then meats. Some recommend veggies then fruits. One item is introduced at an interval of 4-7 days to allow indication of food allergies. Introduction of solid foods is primarily for taste and chewing NOT growth.

Automobile Safety

Car or truck and hot weather-An automobile-related hazard for infants is overheating (hyperthermia) and subsequent death when left in a vehicle in hot weather (>26.4° C [80° F]). Infants dissipate heat poorly, and an increase in body temperature may cause death in a few hours. Caution parents against leaving infants in a vehicle alone for any reason.Air bags-Avoid placing infant in a car restraint behind an air bag. Deactivate the air bag (available in certain models) or place the infant in the back seat in a proper car seat restraint.

Growth Motor Development: Locomotion

Cephalocaudal direction of development Crawling: ages 6 to 7 monthd Creeping: Age 9 months Walking with assistance: Age 11 months Walking alone: Age 1 year

Developmental Nighttime Crying

Child 6-12 months of age with undisturbed nighttime sleep now awakens abruptly; may be accompanied by nightmares. Reassure parents that this phase is temporary. Enter room immediately to check on child, but keep reassurances brief. Avoid feeding, rocking, taking to parent's bed, or any other routine that may initiate trained nighttime crying

Nighttime Feeding

Child has prolonged need for middle-of-night bottle or breastfeeding. Child goes to sleep at breast or with bottle. Awakenings are frequent (may be hourly). Child returns to sleep after feeding; other comfort measures (e.g., rocking or holding) are usually ineffective. Increase daytime feeding intervals to 4 hours or more (may need to be done gradually). Offer last feeding as late as possible at night; may need to gradually reduce amount of formula or length of breastfeeding. Offer no bottles in bed. Put to bed awake. When child is crying, check at progressively longer intervals each night; reassure child but do not hold, rock, take to parent's bed, or give bottle or pacifier.

Development of Body Image (Toddler)

Child refers to body parts by name Child recognizes words used to describe appearance -adults should avoid negative labels about physical appearance. Child recognizes gender differences by age 2. They can also recognize themselves in the mirror.

Refusal to go to Sleep

Child resists bedtime and comes out of room repeatedly. Nighttime sleep may be continuous, but frequent awakenings and refusal to return to sleep may occur and become a problem if parent allows child to deviate from usual sleep pattern. Evaluate if hour of sleep is too early (child may resist sleep if not tired). Help parents establish consistent before-bedtime routine and enforce consistent limits regarding child's bedtime behavior. If child persists in leaving bedroom, close door for progressively longer periods. Use reward system with child to provide motivation.

Nighttime Fears

Child resists going to bed or wakes during night because of fears. Child seeks parent's physical presence and falls asleep easily with parent nearby unless fear is overwhelming. Evaluate if hour of sleep is too early (child may fantasize when nothing to do but think in dark room). Calmly reassure frightened child; keeping night light on may be helpful. Use reward system with child to provide motivation to deal with fears. Avoid patterns that can lead to additional problems (e.g., sleeping with child or taking child to parent's room). If child's fear is overwhelming, consider desensitization (e.g., progressively spending longer periods of time alone; consult professional help for protracted fears). Distinguish between nightmares and sleep terrors (confused partial arousals).

Trained Nighttime Crying (Inapproproate Sleep Associations) Management:

Child typically falls asleep in place other than own bed (e.g., rocking chair or parent's bed) and is brought to own bed while asleep; on awakening, cries until usual routine is instituted (e.g., rocking). Put child in own bed when awake. If possible, arrange sleeping area separate from other family members. When child is crying, check at progressively longer intervals each night; reassure child, but do not resume usual routine.

Development of Body Image

Concept of object permanence By end of first year, recognize that they are distinct from parents. Development of body image parallels sensory motor development. (smiling at each other) Kinesthetic and tactile experiences are children's first perceptions of their bodies (putting things in mouth)

Maturation of Systems

Continues abdominal breathing Respiratory rate slows Short, straight eustachian tube closely communicates with ear and opens the door for infection

Psychosocial Development in Toddlers

Developing a sense of autonomy (Erikson) Autonomy versus shame and doubt Negativism Ritualization that provides sense of comfort

Psychosocial Development

Developing a sense of trust (Erikson) Infants trust that their comfort needs will be met: feeding, stimulation Mistrust: occurs when gratification of needs is delayed Social modifications: grasping, biting

dietary fats nursing alert

Dietary fat in infants younger than 6 months of age should not be restricted unless on specific medical advice. Substituting skim or low-fat milk is unacceptable, since the essential fatty acids are inadequate and the solute concentration of protein and electrolytes, such as sodium, is too high.

Safety Alert Emergency Management of Anaphylaxis

Drug: Epinephrine 0.01 mg/kg of 1 mg/ml solution up to maximum of 0.3 mg Dose: • EpiPen Jr (0.15 mg) intramuscularly (IM) for child weighing 8 to 25 kg (17.5 to 55 lbs) • EpiPen (0.3 mg) IM for child weighing 25 kg (55 lbs) or more Observe for adverse reactions, such as tachycardia, hypertension, irritability, headaches, nausea, and tremors.

Nurses Role in injury Prevention

Education Anticipatory guidance (an appreciation of the hazards or conflict of each developmental period) Ensuring safety in the home. Encourage infant CPR.

Electrical Burns or burns

Electrical outlets-Place safety cap over electrical outlets; infants may be burned by placing conductive object into outlet.Hot hair styling appliances (curlers, flat irons)Keep out of reach of infant and keep turned off when not in use.Water-Infants may turn on tap or faucet in bathtub and burn self. Lower the water heater to a safe temperature of 49° C (120° F). Before placing infant in tub, check temperature of water and completely turn off faucet so child cannot alter temperature of water. NEVER leave infant unattended in tub or sink of water.Fireplace-Place a childproof screen in front of fireplace.Stove, hot liquids-Keep top front burners off and keep pot handles turned toward back to avoid infant pulling hot pot onto self and causing burn injuries.Cigarettes-Avoid smoking and holding infant on lap while smoking cigar or cigarette.

Teething

Eruption of deciduous (primary) teeth. The age varies among children, but the order is usually regular and predictable. The first primary teeth to erupt are lower central incisors. Usually 6 to 10 months of age. Infants may bite on hard objects, increase sucking, or hold their ear to show signs of discomfort. Topical ointments can be rubbed on the gums, but it can destroy the oxygen carrying component of the hemoglobin.

Atopic Dermatitis

Excess inflammation; dry skin, redness, and itching from allergies and irritants. Hydrate skin and minimize flare ups by using a milk soap. Prevent secondary infection by prevent breaking the skin. Can put clean cotton or socks on the hands.

Seborrheic Dermatitis (Cradle Cap)

Excessive thick scaling on the scalp of younger infants. Treated by softening and removal of the thick scales on the scalp after soaking scalp a few hours (to overnight) with vegetable oil or mineral oil. Shampoo scalp and gently scrub scales with soft comb. Prevention is by frequent shampooing with mild baby shampoo and removing scales with soft brush or comb. Self-limiting condition and resolves spontaneously within a few months. Shampoo daily with mild soap or cradle shampoo.

Guidance During the Infant's First Year

First 6 Months • Teach parents car safety with use of federally approved restraint, facing rearward, in the middle of the back seat—not in a front seat with an air bag. • Understand each parent's adjustment to the newborn, especially mother's emotional needs after birth. • Teach care of infant, and help parents understand his or her individual needs and temperament and that the infant expresses wants through crying. • Reassure parents that infant cannot be spoiled by too much attention during the first 4 to 6 months. • Encourage parents to establish a schedule that meets needs of child and themselves. • Help parents understand infant's need for stimulation in environment. • Support parents' pleasure in seeing child's growing friendliness and social response, especially smiling. • Plan anticipatory guidance for safety. • Stress need for childhood immunizations. • Prepare for introduction of solid foods. Second 6 Months • Prepare parents for child's "stranger anxiety." • Encourage parents to allow child to cling to them and avoid long separation from either. • Guide parents concerning discipline because of infant's increasing mobility. • Encourage use of negative voice and eye contact rather than physical punishment as a means of discipline. • Encourage showing most attention when infant is behaving well, rather than when infant is crying. • Teach injury prevention because of child's advancing motor skills and curiosity. • Encourage parents to leave child with suitable caregiver to allow some free time. • Discuss readiness for weaning. • Explore parents' feelings regarding infant's sleep patterns.

Nutrition

First 6 months. Whole milk is not an acceptable source of nutrition. Breast milk is the recommended source. Before 6 months the baby's digestive system is not ready to absorb foods. Breastfed babies reduce the risk of obesity and non breast fed predisposes the child for risk of allergies. Al infants receive daily supplement of 400 iu of vitamin D beginning the first few days to prevent Ricketts and vitamin D deficiency.

Centration

Focusing on one aspect rather than considering all possible alternatives Example: Child refuses to eat a food because of its color, even though its taste and smell are acceptable. Implication: Accept child's reasoning.

Asphyxia, animal bites

Food items: cylindric items such as hot dogs, hard candy, nuts. Cut hot dogs lengthwise; avoid hard candy in infants and toddlers. Infants should completely chew up each food item in mouth; do not feed more until item is swallowed. Toys: small toys such as Legos-As a general rule of thumb, if the toy fits into a toilet paper cardboard roll, it can be swallowed by a small child. Small objects: batteries, buttons, beads, dried beans, syringe caps, safety pins. Keep out of reach of infants, who are naturally inquisitive. Pacifiers-Pacifiers should be one piece .Baby (talc) powder-Avoid shaking powder over infant; if used, place on adult's hand and then place on infant's skin. Domestic dogs, cats-Supervise child around domestic animals; teach not to approach dog that is eating, has puppies, or is not feeling well. Animals that are "tame" can be unpredictable. Small children are the right size for most domesticated animals to come face to face. Closely supervise child around visiting pets.

Fine Motor Development

Grasping object: ages 2 to 3 months Transferring object between hands: age 7 months Pincer grasp: age 10 months Removing objects from container: age 11 months Building tower of two blocks: age 1 year

Gross Motor Development

Head lag in first 2 months Head control at 4 months Parachute reflex by 7 months Sit alone by 7 months Move from prone to sitting position by 10 months Rolling over abdomen to back age 5 months Rolling over back to abdomen 6 months

Spoon Feeding

Helps prevent infant from pushing out food with their tongue.

Egocentrism

Inability to envision situations from perspectives other than one's own Example: If a person is positioned between the toddler and another child, the toddler, who is facing the person, will explain that both children can see the middle person's face. The young child is unable to realize that the other person views the middle person from a different perspective, the back. Implication: Avoid moralizing about "why" something is wrong if it requires an understanding of someone else's feelings or opinion. Telling a child to stop hitting because hitting hurts the other person is often ineffective because to the aggressor it feels good to hit someone else. Instead emphasize that hitting is not allowed.

Inability to Conserve

Inability to understand the idea that a mass can be changed in size, shape, volume, or length without losing or adding to the original mass (instead children judge what they see by the immediate perceptual clues given to them) Example: If two lines of equal length are presented in such a way that one appears longer than the other, child will state that one line is longer even if child measures both lines with a ruler or yardstick and finds that each has the same length. Implications: Change the most obvious perceptual clue to reorient child's view of what is seen. For example, give medicine in a small medicine cup rather than a large cup because child will imagine that the large vessel contains more liquid. If child refuses the medicine in the small cup, pour it into a large cup, because the liquid will appear to be less in a tall, wide container. • Give a large, flat cookie rather than a thick, small one, or do the reverse with meat or cheese; child will usually eat larger size of favorite food and smaller size of less favorite food.

Irreversibility

Inability to undo or reverse actions initiated physically Example: When told to stop doing something such as talking, child is unable to think of positive activity. Implication: State requests or instructions positively (e.g., "Be quiet.")

Pathophysiologic Causes of Failure to Thrive

Inadequate caloric intake: Incorrect formula preparation, neglect, food fads, excessive juice consumption, lack of food availability, breastfeeding problems, behavioral problems affecting eating, or central nervous system problems affecting intake Inadequate absorption: Food allergy, malabsorption, pyloric stenosis, GI atresia, inborn errors of metabolism Excessive caloric expenditure: Hyperthyroidism, malignancy, congenital heart disease, chronic pulmonary disease, or chronic immunodeficiency

Epidemiology of Sudden Infant Death Syndrome

Incidence-1545 per 100,000 live births (2014)*Peak age2-3 months; 95% occur by 6 months; preterm infants die from sudden infant death syndrome (SIDS) at mean age of 6 weeks later than mean age of death from SIDS for term infants. Sex-Higher percentage of boys affected. Time of death-During sleep. Time of year-Increased incidence in winter. Racial-Greater incidence in African-Americans and Native Americans (see the "Sudden Infant Death Syndrome" section earlier in this chapter)Birth Higher incidence in the following: • Preterm infants, especially infants of extremely and very low birth weight • Multiple births† • Neonates with low Apgar scores • Infants with central nervous system disturbances and respiratory disorders such as bronchopulmonary dysplasia • Increasing birth order (subsequent siblings as opposed to firstborn child) Health status-Infants with a recent history of illness; lower incidence in immunized infants. Sleep habits- Highest risk associated with prone position; use of soft bedding; overheating (thermal stress); cosleeping with adult, especially on sofa or noninfant bed; higher incidence in cosleeping with adult smoker Infants cosleeping with adult at higher risk if younger than 11 weeks of age Feeding habits-Lower incidence in breastfed infants. Pacifier-Lower incidence in infants put to sleep with pacifier. Siblings-May have greater incidence in siblings of SIDS victims. Maternal-Young age; cigarette smoking, especially during pregnancy; poor prenatal care; substance abuse (heroin, methadone, cocaine). A few studies have shown an increased risk in infants exposed to second-hand environmental tobacco smoke.

Factors That Affect Iron Absorption

Increase • Acidity (low pH)—Administer iron between meals (gastric hydrochloric acid). • Ascorbic acid (vitamin C)—Administer iron with juice, fruit, or multivitamin preparation. • Vitamin A • Tissue (cellular) need • Meat, fish, poultry • Cooking in cast iron pots Decrease • Alkalinity (high pH)—Avoid any antacid preparation. • Phosphates—Milk is unfavorable vehicle for iron administration. • Phytates—Found in cereals • Oxalates—Found in many fruits and vegetables (plums, currants, green beans, spinach, sweet potatoes, tomatoes) • Tannins—Found in tea, coffee • Tissue (cellular) saturation • Malabsorptive disorders • Disturbances that cause diarrhea or steatorrhea • Infection

Appropriate Site, Technique, Needle Size, and Dose for Intramuscular Injections in Infants, Toddlers, and Small Children

Infants and Toddlers • A 16-mm needle was sufficient to penetrate the anterolateral thigh muscle if the needle is inserted at a 90-degree angle without pinching the muscle in children 2, 4, 6, and 18 months of age (Cook & Murtagh, 2002). • A 25-mm needle was necessary to penetrate the thigh muscle when a 45-degree injection technique was employed. Longer needle length is needed to fully deposit the medication into the muscle in children 2, 4, 6, and 18 months of age (Cook & Murtagh, 2002). • Vaccines containing adjuvant such as alum (e.g., DTaP, hepatitis A and hepatitis B, diphtheria-tetanus [DT or Td]) should be given deep into the muscle to prevent local reactions (American Academy of Pediatrics [AAP], 2012; Centers for Disease Control and Prevention [CDC], 2002; Petousis-Harris, 2008; Taddio, Ilersich, Ipp, et al., 2009). • Injecting adjuvant-containing vaccines into subcutaneous tissue increases the incidence of local reactions (Taddio et al., 2009). • 4-month-old infants experienced fewer local side effects (redness, tenderness, and swelling) when immunizations were administered into the anterior aspect of the thigh with a 25-mm (1-inch) needle versus shorter 16-mm (-inch) needle (Diggle & Deeks, 2000). • Localized vaccine reactions were significantly reduced when long needles (25 mm) were used for infant immunizations (Diggle, Deeks, & Pollard, 2006; Petousis-Harris, 2008). • A 16-mm needle may be adequate for injections in small infants, and a 22- to 25-mm (- to 1-inch) needle can be used in infants 2 months of age and older (AAP, 2012). • A 22- to 32-mm (- to -inch) needle is recommended for injections in toddlers if deltoid muscle size is adequate (CDC, 2002). • A minimum of 25-mm needle is recommended for anterolateral thigh injection in toddlers (CDC, 2002). • The dorsogluteal muscle should be avoided in infants and toddlers, and in smaller preschoolers with smaller muscle mass, because of the possibility of damaging the sciatic nerve (AAP, 2012). • In children older than 1 year of age, the deltoid muscle is recommended for IM injections. When multiple vaccines are given, two may be given in the thigh (anterior and lateral) because of its larger size (Diggle, 2003). • Injections in the anterolateral thigh should be given at least 2.5 cm (1 inch) apart so local reactions are less likely to overlap (AAP, 2012). • No research or supportive data were found regarding the amount of medication to be given at the different sites in infants and toddlers. Children and Adolescents • A 22- to 25-gauge needle for all IM childhood immunizations is recommended (AAP, 2012; CDC, 2002). • The deltoid muscle may be used for immunizations in toddlers, older children, and adolescents (AAP, 2012; CDC, 2002). • 16-mm needle for children who weigh less than 60 kg and a 25-mm needle for children 60-70 kg are appropriate for IM injections in the deltoid injection site (Koster, Stellato, Kohn, et al., 2009). • Needle length was found to be the most significant variable for local reactions in children after injection: A 25-mm needle was associated with fewer localized reactions versus a 16-mm needle (Davenport, 2004). • In children older than 1 year of age, the deltoid muscle is recommended for IM injections. When multiple vaccines are given, two may be given in the thigh (anterior and lateral) because of its larger size (Diggle, 2003). • Injections in the anterolateral thigh should be given at least 2.5 cm (1 inch) apart so local reactions are less likely to overlap (AAP, 2012). • IM injections in the buttocks with longer needles and a 90-degree angle are associated with less reactogenicity (Petousis-Harris, 2008).

final sensorimotor stage

Invention of are means through mental combinations: 19-24 months -imitation of behaviors -domestic mimicry (cleaning) -Limited attention span Concept of time is still embryonic

Controlling Diaper Rash

Keep skin dry.* Use superabsorbent disposable diapers to reduce skin wetness. Change diapers as soon as soiled—especially with stool—whenever possible, preferably once during the night. Expose healthy or only slightly irritated skin to air, not heat, to dry completely. Apply ointment, such as zinc oxide or petrolatum, to protect skin, especially if skin is very red or has moist, open areas. Avoid removing skin barrier cream with each diaper change; remove waste material and reapply skin barrier cream. To completely remove ointment, especially zinc oxide, use mineral oil; do not wash vigorously. Avoid overwashing the skin, especially with perfumed soaps or commercial wipes, which may be irritating. May use a moisturizer or non-soap cleanser, such as cold cream or Cetaphil, to wipe urine from skin. Gently wipe stool from skin using a soft cloth and warm water. Use disposable diaper wipes that are detergent- and alcohol-free.

Suffocation, Sleep Position

Latex balloons- Avoid latex balloons except with close adult supervision. Plastic bags- Tie unused plastic bags in a knot and dispose of in a safe container. Bed surface (noninfant) such as sofa or adult bed Avoid placing infants to sleep on sofas, soft bedding, or adult bed. Pillows-Avoid use of pillows for sleep. Soft cushions and blankets Clear bedding of soft cushions and blankets .Prone sleeping-Place infant to sleep on back at all times.

Sources of Lead

Lead-based paint in deteriorating condition Lead solder Lead crystal Battery casings Lead fishing sinkers Lead curtain weights Lead bullets The following may contain lead: • Ceramic ware • Water • Pottery • Pewter • Dyes • Industrial factories • Vinyl miniblinds • Playground equipment • Collectible toys • Artists' paints • Pool cue chalk • Some imported toys or children's metal jewelry Occupations and hobbies involving lead: • Battery and aircraft manufacturing • Lead smelting • Brass foundry work • Radiator repair • Construction work • Furniture refinishing • Bridge repair work • Painting contracting • Mining • Ceramics work • Stained-glass making • Jewelry making

Language Development (Toddler)

Level of comprehension and ability to understand increases. Comprehension is much greater than the number of words a toddler can say. At age 1 year, child uses one word sentences. By age 2 years, child uses multi word sentences.

Gross and Fine Motor Development: Toddler

Locomotion- begin to walk. 12 to 13 months wide stance. 2 to 3 years can grasp an object and release it, jump with both feet and tip toe. Improved manual dexterity between ages 12 to 15 months. Throwing a ball by age 18 months.

Play

Magnifies psychical and psychosocial development. Interaction with others becomes more important. Parallel play, imitation, tactile play, selection of appropriate toys.

Safety Promotion 8 to 12 months

Major Developmental Accomplishments • Crawls or creeps • Stands, holding onto furniture • Stands alone • Cruises around furniture • Walks • Climbs • Pulls on objects • Throws objects • Is able to pick up small objects; has pincer grasp • Explores by putting objects in mouth • Dislikes being restrained • Explores away from parent • Increasingly understands simple commands and phrases Injury Prevention Aspiration • Keep small objects off floor, off furniture, and out of reach of children. • Take care in feeding solid table food to give very small pieces. • Do not use beanbag toys or allow child to play with dried beans. • See also under 4 to 7 Months of Age. Bodily Damage • See under 4 to 7 Months of Age. • Avoid placing televisions or other large objects on top of furniture, which may be overturned when infant pulls self to standing position. Falls • Avoid walkers, especially near stairs.* • Ensure that furniture is sturdy enough for child to pull self to standing position and cruise. • Fence stairways at top and bottom if child has access to either end.* • Dress infant in safe shoes and clothing (soles that do not "catch" on floor, tied shoelaces, pant legs that do not touch floor). Suffocation and Drowning • Keep doors of ovens, dishwashers, refrigerators, coolers, and front-loading clothes washers and dryers closed at all times. • If storing an unused large appliance, such as a refrigerator, remove the door. • Supervise contact with inflated balloons; immediately discard popped balloons, and keep uninflated balloons out of reach. • Fence swimming pools and other bodies of standing water such as decorative fountains; lock gate to swimming pools so only adult can access. • Always supervise when near any source of water, such as cleaning buckets, drainage areas, ponds, toilets. • Keep bathroom doors closed. • Eliminate unnecessary pools of water. • Keep one hand on child at all times when in bathtub. Poisoning • Administer medications as a drug, not as a candy. • Do not administer medications unless prescribed by a practitioner. • Return medications and poisons to safe storage area immediately after use; replace caps properly if a child-protector cap is used. • Have poison control center number (800-222-1222) on telephone and refrigerator. Burns • Place guards in front of or around any heating appliance, fireplace, or furnace. • Keep electrical wires hidden or out of reach. • Place plastic guards over electrical outlets; place furniture in front of outlets. • Keep hanging tablecloths out of reach (child may pull down hot liquids or heavy or sharp objects).

Safety Promotion and Injury Prevention During Infancy Birth to 4 months

Major Developmental Accomplishments • Exhibits involuntary reflexes (e.g., crawling reflex may propel infant forward or backward; startle reflex may cause the body to jerk) • May roll over • Has increasing eye-hand coordination and voluntary grasp reflex Injury Prevention Aspiration • Aspiration is not as great a danger to this age-group, but parents should begin practicing safeguarding early (see under 4 to 7 Months of Age). • Never shake baby powder directly on infant; place powder in hand and then on infant's skin; store container closed and out of infant's reach. • Hold infant for feeding; do not prop bottle. • Know emergency procedures for choking. • Use pacifier with one-piece construction and loop handle. Burns • Install smoke detectors in home. • Do not microwave infant formula or breast milk because this can cause burns because of uneven warming. • Check bathwater temperature. • Do not pour hot liquids when infant is close by, such as sitting on lap. • Beware of cigarette ashes that may fall on infant. • Do not leave infant in sun for more than a few minutes; keep skin covered. • Wash flame-retardant clothes according to label directions. • Use cool-mist vaporizers. • Do not leave child in parked car. • Check surface heat of car restraint before placing child in seat. Suffocation and Drowning • Keep all plastic bags stored out of infant's reach; discard large plastic garment bags after tying in a knot. • Do not cover mattress with plastic. • Use firm mattress and loose blankets, with no pillows. • Make certain crib design follows federal regulations and mattress fits snugly—crib slats 2.375 inches (6 cm) apart.* • Position crib away from other furniture and away from heat radiators. • Do not tie pacifier on a string around infant's neck. • Remove bibs at bedtime. • Never leave infant alone in bath. • Do not leave infant younger than 12 months of age alone on adult or youth mattress or "beanbag" type seats. • Install carbon monoxide monitor. Motor Vehicles • Transport infant in federally approved, rear-facing car seat, preferably in back seat. • Do not place infant on seat (of car) or in lap. • Do not place child in a carriage or stroller behind a parked car. • Do not place infant or child in front passenger seat with an air bag. • Do not leave infant unattended in car, especially in environmental temperatures above 70° F. Falls • Crib rails are fixed and firmly latched. As of 2011, only beds with fixed rails are recommended, but some older models may be in use (suggest purchasing a rail-latching mechanism for older models). • Never leave infant alone on a raised, unguarded surface. • When in doubt as to where to place child, use floor. • Restrain child in infant seat, and never leave child unattended while the seat is resting on a raised surface. • Avoid using a high chair until child can sit well with support. Poisoning • Poisoning is not as great a danger to this age-group, but parents should begin practicing safeguards early (see under 4 to 7 Months of Age). Bodily Damage • Keep sharp or jagged objects such as knives and broken glass out of child's reach. • Keep diaper pins closed and away from infant.

Safety Promotion 4 to 7 months

Major Developmental Accomplishments • Rolls over • Sits momentarily • Grasps and manipulates small objects • Resecures a dropped object • Has well-developed eye-hand coordination • Can focus on and locate very small objects • Has prominent mouthing (oral fixation) • Can push up on hands and knees • Crawls backward Injury Prevention Aspiration • Keep buttons, beads, syringe caps, and other small objects out of infant's reach. • Keep floor free of any small objects. • Do not feed infant hard candy, nuts, food with pits or seeds, or whole or circular pieces of hot dog. • Exercise caution when giving teething biscuits, since large chunks may be broken off and aspirated. • Do not feed infant while he or she is lying down. • Inspect toys for removable parts. • Keep baby powder, if used, out of reach. • Avoid storing large quantities of cleaning fluid, paints, pesticides, and other toxic substances. • Discard used containers of poisonous substances. • Do not store toxic substances in food or drink containers. • Discard used button-size batteries; store new batteries in a safe area. • Know telephone number of local poison control center (800-222-1222). Suffocation • Keep all latex balloons out of reach. • Remove all crib toys that are strung across crib or play yard when child begins to push up on hands or knees or is 5 months of age. Burns • Keep water faucets out of reach. • Place hot objects (cigarettes, candles, incense) on high surface out of child's reach. • Limit exposure to sun; apply sunscreen. Falls • Restrain in a high chair. • Crib rails are fixed and firmly latched. As of 2011, only beds with fixed rails are recommended. Motor Vehicles • See under Birth to 4 Months of Age. Poisoning • Make certain that paint for furniture or toys does not contain lead. • Place toxic substances on a high shelf or in locked cabinet. • Hang plants, or place on high surface rather than on floor. • Know telephone number of local poison control center (800-222-1222). Bodily Damage • Give toys that are smooth and rounded, preferably made of wood or plastic. • Avoid long, pointed objects as toys. • Avoid toys that are excessively loud. • Keep sharp objects out of infant's reach.

Poisoning, Ingestions

Medication, ointments, cream, lotions Medications left in purses or handbags or on a table top can often be ingested by the curious infant. Keep Poison Control Center number readily available ([800]-222-1222). Plants: household plants may be a source of accidental poisoning-Keep plants out of child's reach.Cleaning solutions-Store in locked cabinet or in top cabinet where there are no drawers or shelves for infant to climb on. Avoid storing cleaning and caustic solutions in containers such as a soda bottle or jar—infants and toddlers cannot differentiate a soda from a caustic drain cleaner.Inhalation or oral or nasal ingestion of poisonous or harmful chemicals such as methamphetamine, gasoline, turpentine-Keep gasoline and turpentine stored in a locked cabinet or closet out of child's reach. Avoid storing in containers that are also used to keep drinks or food.

Maturation of Systems: Toddler

Most physiologic systems relatively mature by the end of toddlerhood Upper respiratory infections, otitis media, and tonsillitis are common among toddlers Voluntary control of elimination: Sphincter control age 18 to 24 months Body temperature is maintained Child is physiologically able to control elimination Defense mechanisms of skin are intact

Atraumatic Care Immunizations

Needle length is an important factor and must be considered for each individual child; fewer reactions to immunizations are observed when the vaccine is given deep into the muscle rather than into subcutaneous tissue. Deep intramuscular tissue has a better blood supply and fewer pain receptors than adipose tissue, thus providing an optimum site for immunizations with fewer side effects (Taddio, Ilersich, Ipp, et al., 2009).

Nutrition (Toddler)

Phenomenon of physiologic anorexia, picky eaters. Give planned frequent and nutritious snacks. Develop bedtime routines.

Assessing Toilet Training Readiness

Physical Readiness • Voluntary control of anal and urethral sphincters, usually by 24 to 30 months of age • Ability to stay dry for 2 hours; decreased number of wet diapers; waking dry from nap • Regular bowel movements • Gross motor skills of sitting, walking, and squatting • Fine motor skills to remove clothing Mental Readiness • Recognizing urge to defecate or urinate • Verbal or nonverbal communicative skills to indicate when wet or has urge to defecate or urinate • Cognitive skills to imitate appropriate behavior and follow directions Psychologic Readiness • Expressing willingness to please parent • Ability to sit on toilet for 5 to 8 minutes without fussing or getting off • Curiosity about adults' or older sibling's toilet habits • Impatience with soiled or wet diapers; desire to be changed immediately Parental Readiness • Recognizing child's level of readiness • Willingness to invest time required for toilet training • Absence of family stress or change such as a divorce, moving, new sibling, or imminent vacation

Feeding the Child With Failure to Thrive

Provide a primary core of staff to feed the child. The same nurses are able to learn the child's cues and respond consistently. Provide a quiet, unstimulating atmosphere. A number of children with failure to thrive (FTT) are very distractible, and their attention is diverted with minimal stimuli. Older children do well at a feeding table; bottle-fed infants and children should always be held. Maintain a calm, even temperament throughout the meal. Negative outbursts may be commonplace in this child's habit formation. Limits on eating behavior definitely need to be provided, but they should be stated in a firm, calm tone. If the nurse is hurried or anxious, the feeding process will not be optimized. Talk to the child by giving directions about eating. "Take a bite, Lisa" is appropriate and directive. The more distractible the child, the more directive the nurse should be to refocus attention on feeding. Positive comments about feeding are actively given. Be persistent. This is perhaps one of the most important guidelines. Parents often give up when the child begins negative feeding behavior. Calm perseverance through 10 to 15 minutes of food refusal will eventually diminish negative behavior. Although forced feeding is avoided, "strictly encouraged" feeding is essential. Maintain a face-to-face posture with the child when possible. Encourage eye contact, and remain with the child throughout the meal. Introduce new foods slowly. Often these children have been exclusively bottle-fed. If acceptance of solid foods is a problem, begin with pureed food and, after it is accepted, advance to junior and regular solid foods. Follow the child's rhythm of feeding. The child will set a rhythm when the previous conditions are met. Develop a structured routine. Disruption in other activities of daily living has great impact on feeding responses, so bathing, sleeping, dressing, playing, and feeding are structured. The nurse should feed the child in the same way and place as often as possible. The length of the feeding should also be established (usually 30 minutes).

Using Car safety Restraints

Read manufacturer directions, and follow them exactly. • Anchor safety seat securely to automobile seat, and apply harness snugly to child. • Do not start the car until everyone is properly restrained. • Always use the restraint, even for short trips. • If child begins to climb out or undo the harness, firmly say, "No." It may be necessary to stop the car to reinforce the expected behavior. Use rewards to encourage cooperative behavior. • Encourage child to help attach buckles, straps, and shields, but always double-check fastenings. • Decrease boredom on long trips. Keep soft toys in the car for quiet play; talk to child; point out objects, and teach child about them. Stop periodically. If child wishes to sleep, make certain that he or she stays in the restraint. • Insist that others who transport children also follow these safety rules.

Car Seat Nursing Alert

Rear-facing infant safety seats must not be placed in the front seats of cars equipped with an air bag on the passenger side. If an infant safety seat is placed in the passenger seat with an air bag, the child could be seriously injured if the air bag is released, since rear-facing infant seats extend closer to the dashboard

Transductive Reasoning

Reasoning from the particular to the particular Example: Child refuses to eat a food because something previously eaten did not taste good. Implication: Accept child's reasoning; offer refused food at a different time.

Global Organization

Reasoning that changing any one part of the whole changes the entire whole Example: Child refuses to sleep in room because location of bed is changed. Implication: Accept child's reasoning; use same bed position or introduce change slowly.

Diaper Dermatitis

Red, moist, maculopapular patch with poorly defined borders in diaper area, extending along inguinal and gluteal folds. History of infrequent diaper changes or occlusive coverings. Inflammatory disease caused by skin irritation from ammonia, heat, moisture, occlusive diapers. Greater incidence in bottle fed infants.

Dental Health in Toddlers

Regular dental exams Removal of plague- brushing and flossing Fluoride Caries- education

Child Home Safety Checklist

Safety: Fire, Electrical, Burns • Guards in front of or around any heating appliance, fireplace, or furnace (including floor furnace)* • Electrical wires hidden or out of reach* • No frayed or broken wires; no overloaded sockets • Plastic guards or caps over electrical outlets; furniture in front of outlets* • Hanging tablecloths out of reach, away from open fires* • Smoke detectors tested and operating properly • Kitchen matches stored out of child's reach* • Large, deep ashtrays throughout house (if used) • Small stoves, heaters, and other hot objects (cigarettes, candles, coffee pots, slow cookers) placed where they cannot be tipped over or reached by children • Hot water heater set at 49° C (120° F) or lower • Pot handles turned toward back of stove, center of table • No loose clothing worn near stove • No cooking or eating hot foods or liquids with child standing nearby or sitting in lap • All small appliances, such as iron, turned off, disconnected, and placed out of reach when not in use • Cool, not hot, mist vaporizer if used • Fire extinguisher available on each floor and checked periodically • Electrical fuse box and gas shutoff accessible • Family escape plan in case of a fire practiced periodically; fire escape ladder available on upper-level floors • Telephone number of fire or rescue squad and address of home with nearest cross street posted near phone Safety: Suffocation and Aspiration • Small objects stored out of reach* • Toys inspected for small removable parts or long strings* • Hanging crib toys and mobiles placed out of reach • Plastic bags stored away from young child's reach; large plastic garment bags discarded after tying in knots* • Mattress or pillow not covered with plastic or in manner accessible to child* • Crib design according to federal regulations (crib slats less than 2.375 inches [6 cm] apart) with snug-fitting mattress* † • Crib positioned away from other furniture or windows* • Portable play yard gates up at all times while in use* • Accordion-style gates not used* • Bathroom doors kept closed and toilet lids down* • Faucets turned off firmly* • Pool fenced with locked gate • Proper safety equipment at poolside • Electronic garage door openers stored safely, and garage door adjusted to rise when door strikes object • Doors of ovens, trunks, dishwashers, refrigerators, and front-loading clothes washers and dryers kept closed* • Unused appliance, such as a refrigerator, securely closed with lock or doors removed* • Food served in small, non-cylindric pieces* • Toy chests without lids or with lids that securely lock in open position* • Buckets and wading pools kept empty when not in use* • Clothesline above head level • At least one member of household trained in basic life support (cardiopulmonary resuscitation), including first aid for choking Safety: Poisoning • Toxic substances, including batteries, placed on a high shelf, preferably in locked cabinet • Toxic plants hung or placed out of reach* • Excess quantities of cleaning fluid, paints, pesticides, drugs, and other toxic substances not stored in home • Used containers of poisonous substances discarded where child cannot obtain access • Telephone number of local poison control center (800-222-1222) and home address with nearest cross street posted near phone • Medicines clearly labeled in childproof containers and stored out of reach • Household cleaners, disinfectants, and insecticides kept in their original containers, separate from food and out of reach • Smoking in areas away from children Safety: Falls • Nonskid mats, strips, or surfaces in tubs and showers • Exits, halls, and passageways in rooms kept clear of toys, furniture, boxes, or other items that could be obstructive • Stairs and halls well lighted, with switches at both top and bottom • Sturdy handrails for all steps and stairways • Nothing stored on stairways • Treads, risers, and carpeting in good repair • Glass doors and walls marked with decals • Safety glass used in doors, windows, and on walls • Gates on top and bottom of staircases and elevated areas, such as porch, fire escape* • Guardrails on upstairs windows with locks that limit height of window opening and access to areas such as fire escape* • Crib side rails raised to full height; mattress lowered as child grows* • Restraints used in high chairs, walkers, or other baby furniture; preferably walkers not used* • Scatter rugs secured in place or used with nonskid backing • Walks, patios, and driveways in good repair Safety: Bodily Injury • Knives, power tools, and unloaded firearms stored safely or placed in locked cabinet • Garden tools returned to storage racks after use • Pets properly restrained and immunized for rabies • Swings, slides, and other outdoor play equipment kept in safe condition • Yard free of broken glass, nail-studded boards, other litter • Cement birdbaths placed where young child cannot tip them over* • Furniture anchored so child cannot pull down on top of self when climbing or pulling to stand

Cognitive Develop in Toddlers

Sensorimotor and preoperational phase (Piaget) Cognitive processes develop rapidly between ages 12 and 24 months. Tertiary circular reactions: active experimentation (to achieve previously unattainable goals), applying knowledge to new situations, learning spatial relationships. Aware of objects.

Social Development (Toddler)

Separation: Differentiation of self from mother and significant others. Individualization: Achievements that mark the child's expression. Major achievements occur in the toddler years. Transitional objects can be a blanket or toy that proved security when separated from care givers.

Sleep and Activity

Sleep patterns vary among infants. By ages 3-4 months, nocturnal sleep lasts 9-11 hours. Breastfed awakened infants more often. Try to avoid excessive use if play pins or strollers because it prevents the infants from exploring by limiting excessive movement

Falls

Stairs-Infants like to climb; place childproof gate at top and bottom of stairs.Diaper changing tableI-nfants do not have depth perception and cannot perceive a dangerous height from one that is safe. Never leave infants unattended on a flat surface, even if not rolling over. Crib, bed-crib sides can fall when infant leans on them.In 2011, a mandate was made to stop selling drop-side infant cribs.*Infant carriers-Never leave infant unattended in a carrier on top of a surface such as a shopping cart, clothes dryer, washer, kitchen cabinet; place carrier on floor.Car seat restraints-Secure infant in car seat restraint and never leave unattended if unrestrained.High chair-Restrain infant in high chair; avoid using high chair except for feeding and only if adult supervision is adequate; even restrained infants can squirm out of some restraints and fall.Infant walkers-Use only stationary walkers. There is no evidence that walkers help infants "walk" any sooner. Wheeled walkers can easily be propelled off stairs and other platforms such as porches or decks, causing significant injury.Windows, screens-Avoid placing furniture next to a window. Infants learn to climb and can fall out of open windows, even with screens. Television, stereos, sound systems-These must be secured to the stand; infants can pull the stand over, causing the TV or sound system to land on their heads, causing significant injury.

Immunization Nursing Alert

The use of meningococcal and diphtheria proteins in combination vaccines does not mean the child has received adequate immunization for meningococcal or diphtheria illnesses; the child must be given the appropriate vaccine for that specific disease.

vitamin D nursing alert

There are reports of accidental overdoses of liquid vitamin D in infants caused by packaging errors; the syringe for liquid administration may not be labeled clearly for 400 IU. Nurses should educate parents to read the syringe and to avoid administering more than 400 IU of vitamin D

Personal Social Behavior in Toddlers

Toddlers develop skills of independence. Skills for independence may result in determined, strong willed, volatile behaviors. Skills include feeding, playing, dressing, and undressing self. Toddlers develop concern for the feelings of others.

Concerns Related to Normal Growth and Development (Toddler)

Toilet training, sibling rivalry, temper tantrums, negativism, regression.

Burn Safety

Turn pot handles toward back of stove. Place electrical appliances such as coffee maker and toaster toward back of counter. Place guardrails in front of radiators, fireplaces, or other heating elements. Store matches and cigarette lighters in locked or inaccessible area; discard carefully. Place burning candles, incense, hot foods, and cigarettes out of reach. Do not let tablecloth hang within child's reach. Do not let electric cord from iron, curling iron, or other appliance hang within child's reach. Cover electrical outlets with protective plastic caps. Keep electrical wires hidden or out of reach. Do not allow child to play with electrical appliance, wires, or lighters. Stress danger of open flames; teach what "hot" means. Always check bath-water temperature; adjust water heater temperature to 49° C (120° F) or lower; do not allow children to play with faucets. Apply sunscreen when child is exposed to sunlight (all year round).

Sensory Changes in Toddlers

Visual acuity of 20/40 acceptable Hearing, smell, taste, and touch development increase Use all senses to explore environment

Assessing Readiness for Toilet Training

Voluntary sphincter control Able to stay dry for 2 hours Fine motor skills to remove clothing Willingness to please parents Curiosity about adult's or sibling's toilet habits Impatient with wet or soiled diapers

milk nursing alert

Warming expressed milk in a microwave decreases the availability of anti-infective properties and nutrients (Labiner-Wolfe & Fein, 2013). To prevent oral burns from uneven warming of the milk, breast milk should never be thawed or rewarmed in a microwave oven. To thaw the frozen milk, either place the container under a lukewarm water bath (<40.5° C [105° F]), or place in a refrigerator overnight.

Proportional Changes in Toddlers

Weight gain slows to 4 to 6 pounds/year. Birth weight should be quadrupled by age 2.5 years. Heigh increased about 3 inches/year. Elongation of legs rather than trunk/ Growth is step-like rather than linear.

Social Development

attachment occurs between 4 to 8 months of age leading to separation anxiety 6 to 8 months the infant is able to discriminate between familiar and unfamiliar people known as strange fear

Positional Plagiocephaly

flattening of one side of an infant's head from prolonged lying in one position. A helmet worn 23 hours a day for 3 months and exercises are used. Teach preventative measures.

Heavy metal poisoning

lead poisoning- usually no signs or symptoms diagnosed with blood specimen screening for high risk children. Chelation therapy removes lead from the blood, organs and tissues Mostly reversible. Most effect is on the CNS. Identify sources of lead.

Safety promotion (Toddler)

motor vehicle safety- car seat restraints Drowning- 12 months to 36 months Is highest risk Burns- fireplace, candles, irons, cigarettes, electrical outlets Aspiration and suffocation Falls Bodily Injury Anticipatory Guidance- education to families

Colic (Paroxysmal Abdominal Pain)

occurs in 5 to 20% of all infants Rule of threes- crying and fussing for more than 3 hours per day, more than 3 days per week, lasting more than 3 weeks per infant. Symptoms usually occur in the evening an dis most common in infants less than 3 months, Multifactorial Cause- too rapid of a feeding, overeating, swallowing excess air, poor feeding technique, stress. infants with cow and milk allergies have a higher risk. No specific treatment

Failure to Thrive

read in the book because this slide was trash

Breast/Bottle Weaning

should be gradual, replacing one feeding session at a time. Nighttime feeding usually last feeding to be discontinued. Do one feeding session at a time not all at once.

Sucking

sucking is an infants chief pleasure. Thumb sucking and pacifiers are normal at this age. There is some evidence that suggest pacifiers reduce the incidence of SIDS, but are higher risk for otitis media (ear infections). Malocculsion can occur after permanent teeth are present with thumb sucking. Never put honey on a baby's pacifier, could result in botulism.

sudden infant death syndrome (SIDS)

the unexplained death of a seemingly healthy baby cause is unknown: but there are hypothesis that there is a brain stem abnormality, sleep apnea, or a genetic link. There is a strong genetic link and high risk between siblings. Lower incidence with breastfed babies. Smoking causes increased risk.

Head Lag

when the infant is lifted from the bed, the head will fall back, because newborn cannot maintain neutral position of the head

Anticipatory Guidance 24 to 36 Months

• Discuss importance of imitation and domestic mimicry and need to include child in activities. • Discuss approaches toward toilet training, particularly realistic expectations and attitude toward accidents. • Stress uniqueness of toddlers' thought processes, especially through their use of language, poor understanding of time, causal relationships in terms of proximity of events, and inability to see events from another's perspective. • Stress that discipline still must be structured and concrete and that relying solely on verbal reasoning and explanation leads to injuries, confusion, and misunderstanding. • Discuss investigation of preschool or day care center toward completion of second year.

Clinical Manifestations of Failure to Thrive

• Growth failure (see earlier in this chapter for definitions) • Developmental delays—social, motor, adaptive, language • Undernutrition • Apathy • Withdrawn behavior • Feeding or eating disorders, such as vomiting, feeding resistance, anorexia, pica, rumination • No fear of strangers (at age when stranger anxiety is normal) • Avoidance of eye contact • Wide-eyed gaze and continual scan of the environment ("radar gaze") • Stiff and unyielding or flaccid and unresponsive • Minimal smiling

Administration of Oral Iron Supplements

• Ideally, iron supplements should be administered between meals for greater absorption. • Liquid iron supplements may stain the teeth; therefore administer with a dropper toward the back of the mouth (side). In older children, administer liquid iron supplements through a straw, or rinse mouth thoroughly after ingestion. • Avoid administration of liquid iron supplements with whole cow's milk or milk products because these bind free iron and prevent absorption. • Educate parents that iron supplements will turn stools black or tarry green. • Iron supplements may cause transient constipation. Caution parents not to switch to a low-iron-containing formula or whole milk, which are poor sources of iron and may lead to iron deficiency anemia (see the "Iron Deficiency Anemia" section in Chapter 43). • In older children, follow liquid iron supplement with a citrus fruit or juice drink (no more than 3-4 oz). • Avoid administration of iron supplements with foods or drinks that bind iron and prevent absorption (see information earlier in this chapter).

Reducing Lead levels

• Make sure that child does not have access to peeling paint or chewable surfaces painted with lead-based paint, especially window sills and wells. • If a house was built before 1978 and has hard-surface floors, wet mop them at least once per week. Wipe other hard surfaces (e.g., window sills, baseboards). If there are loose paint chips in an area, such as a window well, use a wet disposable cloth to pick up and discard them. Do not vacuum hard-surfaced floors or windowsills or wells because this spreads dust. Use vacuum cleaners with agitators to remove dust from rugs rather than vacuum cleaners with suction only. If a rug is known to contain lead dust and cannot be washed, it should be discarded. • Wash and dry child's hands and face frequently, especially before eating. • Wash toys and pacifiers frequently. • Wipe your feet on mats before entering the home, especially if you work in occupations where lead is used. Removing your shoes when you are entering the home is a good practice to control lead. • If soil around home is or is likely to be contaminated with lead (e.g., if home was built before 1978 or is near a major highway), plant grass or other ground cover; plant bushes around outside of house so child cannot play there. • During remodeling of older homes, follow correct procedures. Be certain children and pregnant women are not in the home, day or night, until process is completed. After deleading, thoroughly clean house using cleaning solution to damp mop and dust before inhabitants return. • In areas where the lead content of water exceeds the drinking water standard and a particular faucet has not been used for 6 hours or more, "flush" the cold-water pipes by running the water until it becomes as cold as it will get (30 seconds to 2 minutes). The more time water has been sitting in pipes, the more lead it may contain. • Use only cold water for consumption (drinking, cooking, and especially for reconstituting powder infant formula). • Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. First-flush water may be used for nonconsumption uses (e.g., bathing). • Have water tested by a competent laboratory. This action is especially important for apartment dwellers; flushing may not be effective in high-rise buildings or other buildings with lead-soldered central piping. • Do not store food in open cans, particularly if cans are imported. • Do not use pottery or ceramic ware that was inadequately fired or is meant for decorative use for food storage or service. Do not store drinks or food in lead crystal. • Avoid folk remedies or cosmetics that contain lead. • Avoid candy imported from Mexico (e.g., tamarind hard candy). • Avoid imported toys and toy jewelry that may contain lead. • Make sure that home exposure is not occurring from parental occupations or hobbies. Household members employed in occupations such as lead smelting should shower and change into clean clothing before leaving work. Construction and lead abatement workers may also bring home lead contaminants. • Make sure that child eats regular meals because more lead is absorbed on an empty stomach. • Make sure that child's diet contains sufficient iron and calcium and not excessive fat. • Consider iron supplementation if the child does not regularly consume foods rich in iron.

Managing Colic

• Place infant prone over a covered hot-water bottle or heated towel. • Massage infant's abdomen. • Respond immediately to the crying. • Change infant's position frequently; walk with child's face down and with body across parent's arm, with parent's hand under infant's abdomen, applying gentle pressure. • Use a front carrier for transporting infant. • Swaddle infant tightly with a soft, stretchy blanket. • Take infant for car rides or outside for a change in environment. • Use bottles that minimize air swallowing (curved bottle or inner collapsible bag). • Use a commercial device in the crib that stimulates the vibration and sound of a car ride or plays soothing "noise," in utero sounds, or music. • Provide smaller, frequent feedings; burp infant during and after feedings using the shoulder position or sitting upright, and place infant in an upright seat after feedings. • Introduce a pacifier for added sucking. • If household members smoke, avoid smoking near infant; preferably confine smoking activity to outside of home. • If nothing reduces the crying, place infant in crib and allow to cry; periodically hold and comfort child, and put down again. • Maintain a brief diary of the time of day the crying starts; events going on in household; time, amount, and type of last feeding; length of crying; and characteristics of cry. Although this will not stop the crying, it may help the practitioner identify a possible cause.

Anticipatory Guidance 12 to 18 months

• Prepare parents for expected behavioral changes of toddler, especially negativism and ritualism. • Assess present feeding habits, and encourage gradual weaning from bottle and increased intake of solid foods. • Stress expected feeding changes of picky eating habits, food fads, and strong taste preferences; need for scheduled routine at mealtimes; inability to sit through an entire meal; and lack of table manners. • Assess sleep patterns at night, particularly habit of a bedtime bottle, which is a major cause of early childhood caries (ECC), and procrastination behaviors that delay hour of sleep. • Prepare parents for potential dangers of the home and motor vehicle environment, particularly motor vehicle injuries, drowning, accidental poisoning, and falling injuries; give appropriate suggestions for safety-proofing the home. • Discuss need for firm but gentle discipline and ways to deal with negativism and temper tantrums; stress positive benefits of appropriate discipline. • Emphasize importance for both child and parents of brief, periodic separations. • Discuss toys that use developing gross and fine motor, language, cognitive, and social skills. • Emphasize need for dental supervision, types of basic dental hygiene at home, and food habits that predispose to caries; stress importance of supplemental fluoride (according to age and fluoride content of local water supply).

Communicating with Parents about Immunizations

• Provide accurate and user-friendly information on vaccines (the necessity for each one, the disease each prevents, and potential adverse effects). • Realize that the parent is expressing concern for the child's health. • Acknowledge the parent's concerns in a genuine, empathetic manner. • Tailor the discussion to the needs of the parent. • Avoid judgmental or threatening language. • Be knowledgeable about the benefits of individual vaccines, the common adverse effects, and how to minimize those effects. • Give the parent the vaccine information statement (VIS) beforehand, and be prepared to answer any questions that may arise. • Help the parent make an informed decision regarding the administration of each vaccine. • Be flexible and provide parents with options regarding the administration of multiple vaccines, especially in infants, who must receive multiple injections at 2, 4, and 6 months of age (i.e., allow parents to space the vaccinations at different visits to decrease the total number of injections at each visit; make provisions for office visits for immunization purposes only [does not incur a practitioner fee except for administration of vaccine], provided the child is healthy). • Involve the parent in minimizing the potential adverse effects of the vaccine (e.g., administering an appropriate dose of acetaminophen 45 minutes before administering the vaccine [as warranted]; applying EMLA [lidocaine-prilocaine] or LMX4 [4% lidocaine] to the injection sites before administration; following up to check on the child if untoward reactions have occurred in the past or parent is especially anxious about the child's well-being). • Respect the parent's ultimate wishes.

Anticipatory Guidance 18 to 24 Months

• Stress importance of peer companionship in play. • Explore need for preparation for additional sibling (as appropriate); stress importance of preparing child for new experiences. • Discuss present discipline methods, their effectiveness, and parents' feelings about child's negativism; stress that negativism is an important aspect of developing self-assertion and independence and is not a sign of spoiling. • Discuss signs of readiness for toilet training; emphasize importance of waiting for physical and psychologic readiness. • Discuss development of fears such as darkness or loud noises and habits, such as security blanket or thumb sucking; stress normalcy of these transient behaviors. • Prepare parents for signs of regression in time of stress. • Assess child's ability to separate easily from parents for brief periods under familiar circumstances. • Allow parents opportunity to express their feelings of weariness, frustration, and exasperation; be aware that it is often difficult to love toddlers when they are not asleep! • Point out some of the expected changes of the next year such as longer attention span, somewhat less negativism, and increased concern for pleasing others.