Pediatric Nursing - Flashcards
This article discusses normal growth and development and expected milestones for toddlers (children between one and three years of age).
The Pediatric Nursing series follows along with our Pediatric Nursing Flashcards, which are intended to help nurses and nursing students learn and retain information about caring for pediatric patients. The flashcards are a clear, complete study tool and a helpful reference for practicing RNs, PNs, and other medical professionals.
Physical growth and development milestones for toddlers
Weight, height, gross motor skills, and fine motor skills are among the most common physical growth and development milestones for toddlers.
Weight expectations for toddlers
Toddlers are expected to gain about four to six pounds per year. By age two and a half, their weight should be four times their birth weight. So if a child weighed 6 pounds as an infant, at two-and-a-half years old, they should weigh around 24 pounds.
Height expectations for toddlers
Toddlers grow about three inches per year. Caregivers will notice that at this stage in a toddler’s development, they start to grow up instead of out. Infants tend to be pudgy because they need the weight to help with all of the physical development they do in their first year. After that, they start to stretch out.
Gross motor skills in toddlers
Gross motor skills refer to big movements using big muscles. At 15 months, a toddler should be able to walk without help.
At 18 months, they should be able to jump in place with both feet (bunny hop) and throw a ball overhand. This doesn’t necessarily mean they’re going to be good at throwing the ball, but they should be able to demonstrate that skill.
By two years of age, a toddler should be able to climb stairs and kick a ball. Kicking a ball is a notably complex skill because it requires the toddler to be able to make contact with the ball and propel it forwards as well as have an understanding of where they are in space in relation to the ball.
Fine motor skills in toddlers
Fine motor skills concern little movements using little muscles.
At 15 months, a toddler should be able to successfully build a tower of two cubes.
At 18 months, they should be able to build towers of three to four cubes. They should also be able to use a spoon without rotation, that is, they are able to get the spoon up to their mouth in the correct position.
At two years of age, toddlers should be able to build a six- to seven-cube tower.
By two and a half years, they should be able to build a tower of eight cubes. They will also be able to draw a circle. Toddlers usually accomplish shape-drawing in this order: circle, square, triangle. If you want to remember this, you’ll see it’s in that alphabetical order: C, S, T. The circle comes first as it is a fairly easy thing to draw; the child simply moves their hand around and joins the line at where it started. The more complex shapes take more skill to draw.
Why are towers built from cubes so important in assessing a toddler’s fine motor skill development?
Building towers of certain numbers of cubes is a key way to assess a child’s development. Cube-tower building is part of the Denver II assessment, a formal developmental screening tool that assesses children from birth to 6 years of age, and includes gross and fine motor milestones.
Cognitive development in toddlers: the sensorimotor stage
In terms of cognitive development, toddlers are still in the sensorimotor stage, which means they are still exploring the world using their senses.
Language development in toddlers
At this stage in a toddler’s language development, they begin to use holophrases, which are one-word sentences, for example “Hungry.” This fairly obviously translates as, “I am hungry.” “No.” is another extremely common holophrase. So is “Want.” (“I want whatever it is I am looking at or thinking about.”)
By age two, a toddler should have more than 50 words and two- to three-word phrases. This is when we see explosive growth in their language, comprehension, and use. Toddlers will go from having no language to using all of language very quickly.
Normal behaviors for toddlers
The following are normal behaviors in toddlers.
Ritualization
Ritualization provides a sense of comfort for a toddler. For instance, having a comfort item to sleep with, like a Teddy bear. The consistency of the bear’s presence at bedtime is a ritual. If the Teddy bear is missing when it’s time to go to bed, this will present a problem because the child’s ritual has been disturbed.
Negativism
Negativism is when a toddler automatically says, “No.” — to anything and everything. For example, a caregiver might ask the toddler, “Do you want to have a bite of my sandwich?” And the immediate response from the toddler is “No.” followed by, “What is it?” Their immediate reaction is negativism in action.
Temper tantrums are another expression of negativism. Parents and caregivers may have different experiences of just when temper tantrums occur in their children. For some it’s the “Terrible Twos.” For others, their children are three years old when the tantrums start.
Egocentrism
When someone is egocentric, it means like they are thinking of themselves as if they are the center of the universe. While this may be unwelcome in an adult, egocentrism is very important for a toddler, because they need to fulfill their needs in order to continue to live (survive). Further, they have’t learned how to consider the feelings of others, another hallmark of egocentrism. In practice that means hearing a toddler say “I want” a lot. Toddlers don’t understand sharing because it hasn’t occurred to them that another person might be sad when, for example, they don’t get to play with a particular toy the toddler holds. They can’t see the situation from the other person’s point of view.
Psychosocial development in toddlers: autonomy vs. shame and doubt
A toddler’s psychosocial development at this stage is autonomy versus shame and doubt, the second of Erik Erikson’s stages of psychosocial development.
Age-appropriate play for toddlers
When the child was little, they played on their own, which we call solitary play. As the toddler develops, new modes of play emerge.
Parallel play
Parallel play is when a toddler plays independently next to other children. They are next to each other, but they are not playing together, hence “parallel” play. For example, one toddler might be playing with blocks while the toddler next to them is playing with cars.
The toys that interest a toddler at this stage of their development include push and pull toys, wooden puzzles, blocks, and balls.
Nutrition for toddlers — what parents should know
Parents of toddlers will discover that nutrition can get a little bit intense at this stage of the child’s development, because they are now eating more solid foods but are still at risk for choking.
What milk should a toddler drink?
Whole milk should be introduced into a child’s diet when they reach one year old. At this point, formula may be phased out and replaced with whole milk. At age two, toddlers should be transitioned to 2% milk. Whole milk has lots of fat in it, which is important for developing brains. But by age two, it’s time to cut down the fat content and go to 2% milk.
It is also important to limit milk to two to three servings per day. Too much milk, too much calcium, can decrease a child’s iron, which can lead to anemia.
If cow’s milk is contraindicated for a child, supplement their diet with calcium-rich and high-fat foods.
Limit juice, offer water to toddlers
Juice should either not be given at all or be limited to four to six ounces per day. Juice is sugar-rich, which can have an adverse effect on a child’s dental and physical health. You may have heard dentists say that each bottle of juice comes with its own cavity.
Offer water to a toddler several times a day instead.
Supervise toddlers during meal time
Toddlers are still at risk for choking, so it is important to be aware of choking hazards and supervise children when they eat. Our pevious article on safety issues covered this in more detail.
What is physiologic anorexia in toddlers?
It’s common for young children to experience physiologic anorexia. This is when the child says, “I’m too busy to eat.” They will tell a caregiver that they are running around or playing with their toys, and they don’t want to stop to sit down and eat a meal.
Encourage toddlers to eat healthy foods in small amounts
Instead of making a toddler stop what they are doing for sit-down meals, making available small, healthy finger-foods that they can snack on throughout the day is a good alternative. This is also known as grazing. Consider serving fruits and vegetables that can be cut into small sizes and that are stable at room temperature. The child can come and snack on these when they want to.
Toilet training for toddlers
A child indicates they are ready for toilet training when they start to recognize and communicate they need to use the toilet. What often happens is the child will let their parent or caregiver know that they need to use the bathroom. Note that this announcement might come before or after the child has gone (in their diaper). This is normal; the child has started to recognize that the two — knowing that they have to use the toilet, and doing it — go together.
Two more signs the child is ready for toilet training are when they wake up dry from nap or bedtime and if they are staying dry for two hours at a stretch during the day. Children normally have to go to the toilet every two hours, so when they stay dry for the duration, that indicates that they’re ready to transition to using the toilet rather than a diaper.
Sleep requirements for toddlers
A toddler should get between 11 and 12 hours of sleep each day. This is a lot of sleep, but is important for a child’s brain and physical development.
It is also important to maintain the child’s sleep structure, that is, maintaining a consistent bedtime routine.
Dental health for toddlers
Here are some of the things parents and caregivers should keep in mind when it comes to toddler dental health:
Do not give a toddler a bottle of milk or juice at bedtime.
The parent should brush and floss their child’s teeth right before bedtime as part of the child’s bedtime ritual. Having the child help will teach them to take on the responsibility of their dental care. For instance, the adult might say, “I’m going to brush your teeth first, and then you can brush them.” The child may just wiggle the brush around in their mouth, but they are learning to take care of their teeth!
Just as any adult should, toddlers should be seeing the dentist twice a year.
Toddler vaccination schedule
Note: The charts on our Pediatric Nursing Flashcards are a handy way to get to know the pediatric vaccination schedule for young and older children.
Hep. B, IPV
Between the ages of 6 and 18 months, the child should be getting their third doses for hepatitis B and IPV (the polio vaccine).
MMR, Hib, PCV, varicella
At 12 – 15 mos, the child should receive their MMR, Hib, PCV, and varicella vaccines.
MMR
MMR is the abbreviation for the combined vaccine for measles (an infectious viral disease causing fever and a red rash on the skin), mumps (a contagious disease caused by a virus whose symptoms include swollen salivary glands and a fever), andrubella.
Hib
The vaccine for Hib, haemophilus influenzae b, is very important to help prevent a certain type ofmeningitis.
PCV
PCV is thepneumonia conjugate vaccine, a pneumonia vaccine for younger children. It is administered at around 2 months of age.
Varicella
Varicella is a herpesvirus that causeschickenpox and shingles (a viral infection that causes a painful rash).
MMR and varicella are given at this age because these are live virus vaccines, and children cannot get them until they are at least one year old.
Hep. A
A child should get their hepatitis A vaccine between 12 and 23 months of age. Hep A is used to prevent hepatitis A, a type ofliver disease.
DTaP
A child should get another dose of the DTaP vaccine between 15 and 18 months of age. DTaP is a combined vaccine for diphtheria (highly contagious bacterial disease),pertussis, and tetanus (a serious disease of the nervous system caused by a toxin-producing bacterium).
Influenza
Starting at one-year of age, children should be getting their seasonal influenza vaccine annually, when it is seasonally appropriate.