CARE OF THE TODDLER

Definition:

The toddler age is the developmental period that begins at one year & ends at three. It is the time of intense exploration of the environment as children attempt to find out how things work and how to control others through temper tantrums, negativism and obstinacy. It is an extremely important period for developmental achievement and intellectual growth.

I - PHYSICAL GROWTH AND DEVELOPMENT

A. General Growth Parameters 1. Size increases in step like rather than linear patterns, reflecting the growth spurts and lags characteristics of toddlerhood. a. Height - The average toddler grows about 3 inches (7.5 cm) per year. - The average 2-years-old is about 34 inches (86.5 cm) tall. Height at 2 years is about haft the expected adult height. b. Weight - The average toddler gains from 4 to 6 lb (2 to 2.5 kg) per year. - The average 2-year-old weighs 27 lb (12.2 kg). - Birth weight quadruples by 2 1/2 years. c. Head circumference - From ages 1 to 2 years, head circumference equals chest circumference.

- From ages 1 to 2 years, head circumference equals chest circumference. - The total increase in head circumference in the second year is 1 inch (2.5 cm), then the rate of increase slows to 1/2 inch (1.3 cm) per year until age 5 years. d. Anterior fontanel - closed at 1 1/2 years old\ e. Dentition - 20 teeth at 2 1/2 yrs old. Should start dental care by 2 years old. 2. A toddler's characteristics protruding abdomen results from underdeveloped abdominal muscles. 3. Bowleggedness typically persists through toddlerhood because the leg muscles must bear the weight of the relatively large trunk. Vital signs average: temperature - 37.2 degree Centigrade (99 degree Farenheight) pulse - 110 beat/min respiration - 25 breath/min BP - 97/60 mmHg

Appearance: - appears chubby with short legs & a large head. - have pronounced lumbar lordosis & a protruding abdomen because he is beginning walker. As he walks longer, this will correct itself naturally.

B. Nutrition 1. Nutritional requirements a. Growth rate slows dramatically, thereby decreasing the child's need for calories, protein, and fluid. b. Calorie requirements are 102 kcal/kg/day c. Protein requirements are 1.2 g/kg/day d. Milk should be limited should be to no more than 1 qt (about 1 L) daily to help ensure intake of iron-enriched foods. Hematocrit should be used to screen for anemia. e. Toddlers on vegetarian diets may not receive sufficient plant proteins. They should be referred to a nutritionist.

2. Food preferences and patterns a. By age 18 months, most toddlers eat the same foods as the rest of the family. b. At age 18 months, many toddlers experience physiologic anorexia and become picky eaters, experiencing food jags (wanting a specific food item, such as peanut butter & jelly sandwiches for a period of days), eating large amounts one day & very little the next. c. Toddlers prefer to feed themselves & prefer small portions of appetizing foods. d. Toddlers prefer single foods instead of mixtures of foods. A variety of foods should be offered, but the same foods should be repeated often enough to allow the toddler to recognized them. e. Parents should encourage the use of utensils but be aware that toddlers prefer to use fingers.

C. Sleep patterns 1. Total sleep requirements decrease during the second year to an average of about 12 hours daily. 2. Most toddlers nap once a day until the end of the second or third year. 3. Sleep problems are common & may result from fears of separation. 4. Bedtime rituals & transitional objects that represent security, such as blankets or stuffed toys, are helpful. D. Dental health 1. Primary dentition (20 deciduous teeth) is completed by age 2 1/2 years. 2. The first dental visit should occur before the toddler is 2 1/2 years old.

3. Parents should clean the toddler's teeth with a soft toothbrush & water, and then floss the teeth. They should not use toothpaste because toddlers dislike its foaminess. Fluoridaded toothpaste is dangerous if swallowed. 4. Toddlers require fluoride supplementation if the water in their area is not fluoridaded. 5. Diet should be low in cariogenic foods, such as table sugar, which promote dental caries. E. Elimination 1. Stool appearance changes with additions to diet. Highly colored foods (e.g., gelatin, beets, colored drinks, and blueberries) may color stool. 2. Average urinary output during childhood is 500 to 1,000 ml/day.

Age of Achievement: a. Bowel control 18 months of age b. Daytime bowel control 2 years of age c. Night time bowel control 3 years of age

F. Sensory abilities Visual acuity is fairly well established at 1 year average acuity for the toddler are 20/70 at 18 months and 20/40 at 2 years. Accomodation to near and far objects is fairly well developed by 18 months. The sense of hearing, taste, smell, and touch become increasingly developed and associated with each other. Hearing at 3 years old is at adult level. The taste buds of the toddler are sensitive to the natural flavour of food at 3 years old prefers familiar odor and tastes. Touch is a very important sense and a distressed toddler is often soothed by tactile sensations.

II - MOTOR DEVELOPMENT
MOTOR scribbles spontaneously, pulls walks alone , loses balance, creeps 15A. GROSS MOTOR DEVELOPMENT shoes & socks off, builds a months upstairs, throws objects to floor two block tower runs & falls, walk upstairs with one hand held, creeps downstairs, sits spoon-feeds self, turn back on chair alone, pulls & pushes toy, pages, builds a 3 to 4 block 18 months pulls & pushes toys, helps remove tower clothes goes up & down stairs with both tries to draw vertical & feet on one step, runs well, puts on circular strokes, turn 24 months shoes, socks, pants, remove screw doorknobs, holds glass in one lids from jars hand holds crayons with fingers, draws two vertical jumps with both lines in form of cross, builds an eight-block 30 months feet tower AGE FINE GROSSMOTOR

III - PSYCHOSOCIAL DEVEOPMENT A. Overview (Erikson) 1. Erikson terms the pyschosocial crisis the child faces between ages 1 and 3 as "autonomy versus shame and doubt" a. The psychosocial theme is "to hold on; to let go", b. The toddler had developed a sense of trust & is ready to give up dependence to asset his budding sense of control & autonomy. Parents who encourage the toddler to do so promote the toddler's independence. c. The toddler can develop a sense of shame & doubt if parents keep him dependent in areas where the toddler can use newly acquired skills or make the toddler feel inadequate when attempting these skills. 2. The toddler begins to master social skills. a. Individualization (differentiation of self from others) b. separation from parent c. control over bodily functions d. communication with words

e. Socially acceptable behaviour the toddler begins to learn that his own behaviour has a predictable, reliable effect on others. The toddlers learn to wait longer to gratify needs. f. Egocentric interaction with others. (The toddler may not master some interactive skills until adolescence when he revisits uncomplicated tasks associated with early periods of development. Erikson refers to this as the psychosocial moratorium)

3.The toddler often uses NO even when he means YES to assert independence (negativistic behaviour) 4. A toddler often continues to seek a familiar security object, such as a blanket, during times of uncertainty and stress.

B. Fears 1. Common fears of toddlers include: a. loss of parents (known as separation anxiety) b. stranger anxiety c. Loud noises (e.g. vacuum cleaner) d. going to sleep e. large animals 2. Emotional support, comfort, and simple explanations may allay a toddlers fear.

C. Play and toys 1. Toddlers engage in parallel play, which is play alongside, not with, others (play beside the children next to them). 2. A short attention span causes toddlers to change toys frequently. a. Purposes of toys in toddlers: - To enhance locomotion skills (push-pull toys) - To encourage imitation, language development, and gross & fine motor skills. b. Toys should be safe (still no detachable or small parts). Examples of safe appropriate toys are: Dolls & housekeeping toys Play phones & cloth books Appropriate rocking horses and riding trucks, finger paints, play clay, large-piece wooden or plastic puzzles, and large blocks.

Discipline 1. Unrestricted freedom is a threat to a toddlers security despite limit testing. 2. Tell child specifically why discipline is necessary. 3. Discipline measures should be: a. consistent b. initiated after misbehavior, not the child c. planned in advance d. oriented to behavior, not the child 4. Private and not shame- inducing 5. Avoid power struggles with toddler. a. Parents should carry them out in a safe, non stimulating area. b. Duration should be 1 minute per year. Parents can use audible timer to monitor duration.

PSYCHOSEXUAL DEVELOPMENT Overview (Freud) 1. The anal stage of development extends from age 8 months to 4 years 2. The erogenous zone consists of the anus and buttocks, and sexual activity centers on the expulsion and retention of body waste. a. The toddlers focus shifts from the oral to the anal area, with emphasis on bowel control as he gains neuromuscular control over the anal sphincter. b. the toddler experiences both satisfaction and frustration as he gains control over withholding and expelling containing and releasing. c. The conflict between holding on and letting go gradually resolves as bowel training progresses; resolution occurs once

Manifestation: 1. Sexuality begins to develop. a. Masturbation can result from body exploration. b. Learned words may be associated with anatomy and elimination. c. Sex differences become evident. 2. Toilet training is a major task of toddlerhood. a. Readiness is unusual before age 18 months. b. Bowel training is accomplished before bladder training usually does not occur until age 4 to 6. c. The training potty should offer security; the toddlers feet should reach the floor.

COGNITIVE DEVELOPMENT Overview (Piaget) 1. Sensorimotor Stage. This stage, lasts between ages 12 and 24 months, involves two substages. a. Substage 1 (12 to 18 months) Tertiary circular reactions involve trial-and-error experimentation and relentless exploration. (This stage overlaps with substage 5 in infancy) b. Substage 2 (18 to 24 months) Mental combinations appear, allowing the toddler to devise new means for accomplishing tasks. reasoning

Language
AGE LANGUAGE Uses expressive jargon (specialized language which is only understood by a specific group) Has 4 to 6 words vocabulary Have at least 10 words vocabulary

15 months

18 months

24 months

Has 300 word words vocabulary, uses 2-3 word phrases, uses pronouns Can say first & last names, uses appropriate pronouns & plurals, has vocabulary of over 900 words

30 months

SPIRITUAL DEVELOPMENT Have only a vague idea on God and religious teachings. Routines such as praying before meals or at bedtime can be very important and comforting. MORAL DEVELOPMENT A. Overview (Kohlberg) 1. A toddler is typically at the first substage of the preconventional stage, which is oriented toward punishment and obedience. The toddler bases judgment on avoiding punishment or obtaining a reward. 2. Discipline patterns affect a toddlers oral development. a. Physical punishment and withholding privileges tend to give the toddler a negative view of morals. b. Withholding love and affection as a form of punishment leads to feeling of guilt. B. Appropriate discipline measures include providing simple explanations why certain behaviours are unacceptable, praising appropriate behaviour, and using distraction to avoid unacceptable behaviours.

Behavioural traits: 1. Negativism/ negativistic behaviour the negative response to requests - the words no or me do can be sole vocabulary - uses yes to no when he means assert independence - the best way to decrease the number of nos is to decrease the number of questions that can lead to a no response. - emotions become strongly expressed, usually in rapid mood swings. One minute toddlers can be engrossed in an activity, and in the next minute they might be violently angry because they are unable to manipulate a toy or open a door

2. Ritualism the need to maintain sameness and reliability provides a sense of comfort. Toddlers can venture out with security when they know that familiar people, places, and routines still exist. Without the comfortable rituals, there is little opportunity to exert autonomy. Consequently, dependency and regression occur. 3. Headstrong because they are slowly moving out of infancy and more closely defining their own.

4. The independent activity naturally active, mobile curious which makes them vulnerable to accidents to set limits and exert external control whenever necessary. Remember: Love and consistency are the two most important concepts in child rearing. 5. They are rigid, repetitive, and ritualistic and stereotype in their behaviour. When things are rearranged or are strange, or persons or places are unfamiliar, toddler go into temper tantrums in order to control self and others. 6. Toddlers may use tantrums to assert independence. Caregivers can best deal with them by extinction (ignoring them) or direct them to activities that they can master.

7. Toddlers have very poor sense of time. Their schedules revolve around their activities, not around the clock. 8. Adults should talk to very young children at eye level. The great disparity in size between an adult and a toddler can cause fear in the later. 9. It is the critical period for toilet training. Signs of the toddlers readiness for toilet training: 1. Stays dry for 2 hours, with regular bowel movements 2. Can sit, walk, and squat 3. Can verbalize the desire to void or defecate 4. Exhibits a willingness to please parents 5. Wants to have soiled diapers changed immediately

Note: Toilet training should not be initiated during times of stress, such as the birth of a new baby, a move, a divorce, or a vacation.

ILLNESS AND HOSPITALIZATION A. Reactions to illness 1. The concept of body image, especially body boundaries, is poorly defined in toddlers. Therefore, intrusive procedures are extremely anxiety-producing. 2. Toddlers react to pain similarly to infants, and previous-experiences may affect toddlers as well. They may also get upset if they only perceive that they will experience pain. B. Reactions to hospitalization 1. In response to stressful events, such as hospitalization, the toddlers primary defense mechanism is regression

2.

The toddler may also sense a loss of control related to physical restriction, a loss of routine & rituals, dependency, and fear of bodily injury or pain.

3. Separation affects most toddlers, who view it as abandonment (18 months is the peak age for separation anxiety). Hospitalization may promote separation anxiety, which has three distinct phases: a. Protest. The toddler verbally cries for parents, verbally or physically attacks others, attempts to find parents, clings to parents, and is inconsolable. Screams, cries, kicks, bites, hits strangers, tries to escape to find parents.

b. Despair. The toddler is disinterested in the environment and play & shows passivity, depression, and loss of appetite. Become apathetic, mournful, withdrawn, tries to comfort self with rocking, head banging, thumb sucking, regresses, does not physically resist procedure. c. Detachment (denial). The toddler makes a superficial adjustment and shows apparent interest, but remains detached. This phase usually occurs after prolonged separation and is rarely seen in hospitalized children. After prolonged separation shows interest in environment, appears happy, friendly, forms superficial relationships with strangers, ignores mothers as if forgotten, does not cry when she leaves.

Problems Associated with the Toddler Period 1. Toilet Training When to start toilet training? Begin toilet training when children are ready (18-24 months). Before they can begin toilet training, they must reach the two important developmental levels: a. Physiologic they must have a control on rectal & urethral sphincters. b. Cognitive they must have a cognitive understanding of what it means to be hold (urine & stools until they can release them at a certain place of time.

Ways and Measures: 1. Some parents begin toilet training by sitting him on a potty chair. 2. Introduce the concept of urinating in the bathroom, especially when the child sees their parents or older children in the family using the toilet. 3. Train at regular intervals such as when the child wakes up in the morning, after breakfast, midmorning, before lunch & after lunch and so forth. 4. If the child does urinate or defecate, he should be praised. 5. Some parents wake up children during the night and carry them to the bathroom to void.

2. Dawdling A child who dawdles is one who lingers or dilly dallies with his food during meal. He may be trying to get attention or may not be feeling at all. Often times, he is given which are too large. Management: a. The best advice is to have him regularly checked by a paediatrician and to avoid fussing over. b. Let the child enjoy eating.

3. Ritualistic Behaviour Although toddlers spend a great deal of time every day investigating new ways to do things & doing thing, they have never done before, they also enjoy ritualistic patterns. They will use only their spoon at meal time, only their washcloths at bath time. They will not go outside unless mother or father locates their favourite cap. 4. Negativism As part of establishing their identities as separate individual, toddlers typically go through a period of extreme negativism. They do not want to do anything that a parent wants them to do. Their reply is a very definite NO. This extreme negativism in their child will pass after it runs it course. The more parents attempt to make the child obey them the more the child is likely to resist.

Management: a. A toddlers NO can best be eliminated by limiting the number of questions asked to the child. For example, Will you come to take a bath now? she means Its time for your bath, making statement instead of asking the question, can avoid a great many negative responses. b. A toddler needs to experience in making choices. To provide the opportunity to do this, a parent might give a secondary choice. Example Its bath time now but they says, Do you want to take your duck or your toy boat into the tub with you?

5. Temper Tantrum Almost every toddler has a temper tantrum at one time or another. The child may kick, scream, stamp feet and shout no, and lie on the floor. Children may even hold their breath until they become cyanotic and slump to the floor. Temper tantrums are natural consequences of toddlers development. They are independent enough to know what they want, but they do not have vocabulary. Management a. The best approach is for parents to tell the child simply than they disapprove of the tantrums & then ignore it.

Nursing Care: A. Meet nutritional needs Assess parents ability and or teach parent to meet toddlers need Give meats, fish, eggs, vegetables and fruits Accept developmental deterrents Physiologic anorexia resulting from decreased growth rate, food jags, negativism, ritualism, need to explore, smearing Management: 1. Use small plate, portions and utensils 2. Offer choices when possible 3. Offer nutritious snacks between meals. Instruct parent not to offer snacks within 1 hour of a meal to avoid decreasing toddlers appetite. 4. Add powdered milk to soup and sauces if milk intake has lessened. 5. Toddlers are at risk for aspirating small food items such as peanuts. They can also choke on raw carrots, celery and hotdogs. 6. Remind parents not to use food as a reward or a punishment.

Toddlers should sit at a table or in a high chair to eat, to minimize the chance of choking and to foster positive eating patterns.

B. Protect from injury Assess parents ability and or teach parents how to prevent accidents 1. Poisoning because toddlers are very mobile and curious keep all toxic substances and medicines in locked cavinet, do not offer medicine as candy, keep original labels on all toxic substances, use syrup of ipecac prn, call Poison Control Center Management: identify the poison a. Corrosive Example: Muriatic acid, acetone, paint thinner, petroleum distales Dont induce vomiting Give mineral oil 1-2 tbsp./ cooking oil/ Johnson baby oil, as substitute to prevent adhesion of intestine

b. Non-corrosive Induce vomiting Gag reflex stimulation Syrup of ipecac an oral emetic to cause vomiting after drug overdose or poisoning Child 15 cc + water Adult 30 cc Less than 1 year = 5 to 10 ml followed by glass of H2O; repeat dosage one time if vomiting does not occur in 20 minutes c. Unknown Give universal antidote, charcoal (absorb the poison, preventing from going down to the intestines Acid alkaline (milk of magnesia) Alkaline-acid (vinegar, fruit juices, tea)

2. Motor vehicles restrained in approved car seat, even when car is parked, supervise or place in enclosed area when outside. Do not allow child to play outside unsupervised. 3. Burns teach hot when near stoves, open flames, radiator etc. Monitor toddlers carefully when they near lit candles. 4. Falls keep crib rails fully raised and crib at lowest level, lock doors leading to steps, keep away from open windows, supervise toddler at play 5. Suffocation enclose swimming pool with fence, supervise closely when near swimming water, teach how to swimming. 6.Bodily injury offer sturdy toys with no sharp edges, do not allow to run with pencils or sharp objects, keep dangerous tools & other equipment in locked area.

c. Protect from infection because toddlers are very prone to upper respiratory infection due to close proximity of trachea and bronchi resulting to rapid transmission of infectious agents. d. Protect from dehydration - Assess from dehydration (DHN): sunken eyeballs, dry skin, depressed fontanels, decrease urinary output - Offer variety of clear fluids in small amount - Assess how much fluids are retained by observing frequency and amount of vomiting and diarrhea - continue feeding - seek health care if vomiting and/ or diarrhea persist or worsen

Meet developmental needs 1. Allow to explore under supervision in a controlled environment 2. Allow to gain control of body a. Self-feeding b. Undressing and dressing c. Hygiene: brushing of teeth, bathing 3. Help to gain control of body functions toilet training. Begin training when the child demonstrates clues to readiness for toilet training. 4. Help to tolerate frustration by setting realistic limits & maintaining consistency 5. Reward positive behaviour with praise and affection 6. Discipline consistently, immediately and appropriately, use corporal punishment (spanking) thoughtfully, never anger, for toddlers safety

7. Know developmental milestones, encourage and reward their achievement, avoid unrealistic goals 8. Offer appropriate play materials 9. Know when to seek health/ medical guidance or supervision F. Meet developmental needs during hospitalization 1. Encourage parental participation in care 2. Use toddlers vocabulary for objects and body functions 3. Ask parents to leave favourite toys and / or blanket 4. Continue home routine and rituals when possible

5. Accept regressive behaviour 6. Allow as much mobility as possible 7. Offer age-appropriate diversional play and play activities. 8. Offer therapeutic play materials banging toys, stethoscope, blood pressure cuff 9. Administer medications in medicine cup or allow themselves to take drugs, never use force. Offer choices, when administering medications.

The approach to examination of the toddler is important in order to elicit cooperation. The toddler may accept parts of the examination best when seated on the parents lap.