Chapter 4 TODDLER (18 months-3 years)

TERMS to know.
Animism-Human feelings and characteristics may also be attributed to objects example: I have a talking dog.
Echolalia-(repetition of words and phrases without understanding) normally occurs in toddlers younger than
30 months of age. “Why” and “what” questions dominate the older toddler’s language.
Egocentrism-feel in control of his or her world emerges, the toddler displays.
Expressive language--development (the ability to communicate one’s desires and feelings)
Food During a food jag, the toddler may prefer only one food for several days, and then not want it for weeks.
Individuation-forming a sense of self and learning to exert control over one’s environment.
Parallel play-Toddlers typically play alongside another child.
Physiologic anorexia- Since the toddler’s rate of growth has slowed somewhat compared to that in infancy,
the toddler requires less caloric intake for his or her size compared to the infant.
Receptive language development (the ability to understand what is being said or asked) is typically far more
advanced than expressive language.
Regression-the toddler may want to go back to an earlier stage. He or she may desire a bottle or pacifier
forgotten long ago.
Separation-Seeing oneself as separate from the parent or primary caregiver.
separation anxiety may re-emerge in the 18- to 24-month period (Lieberman, 2018). Power struggles may
escalate and distress at separating from the parent may increase. Again, a predictable routine with an
appropriate limit setting may help toddlers feel safer and more secure during this period.
sibling rivalry-(competition or jealousy between siblings), parents should attempt to keep the toddler’s routine
as close to normal as possible.
telegraphic speech refers to speech that contains only the essential words to get the point across, much like a
telegram. Rather than “I want a cookie and milk,” the toddler might say, “Want cookie milk.”

Physical Growth
 Weight increases steadily in spurts (slower rate than an infant)
 Average weight gain = 3 to 5 lb. per year
 Length/height increases steadily in spurts (slower rate than an infant)
 Average increase of 3 per year
 Fontanels close by 18 months.
 About ½ adult height by age 2
 Head size is more proportional to the body by age 3.

Physiologic Changes
Neurologic system
 Anterior fontanel closes by 18 months.
 Brain = 90% adult size by age 2
 Increased myelination = improved coordination, balance, and sphincter control
Respiratory system
 Alveoli continue to increase in number.
 The trachea and airways remain small compared to adults.
 Tonsils and adenoids are relatively large.
Cardiovascular system
  Heart rate decreases
 Blood pressure increases

Gastrointestinal System The stomach continues to increase in size, allowing the toddler to consume three
regular meals per day. Pepsin production matures by 2 years of age. The small intestine continues to grow in
length, though it does not reach the maximum length of 2 to 3 meters until adulthood. Stool passage
decreases in frequency to one or more per day. The color of the stool may change (yellow, orange, brown, or
green) depending on the toddler’s diet. Since the toddler’s intestines remain somewhat immature, the toddler
often passes whole pieces of difficult-to-digest food such as corn kernels. Bowel control is generally achieved
by the end of the toddler period.
Genitourinary system- Urine output should be about 1 mL/kg/hour. The urethra remains short in both male
and female toddlers, making them more susceptible to urinary tract infections compared to adults.
Musculoskeletal System During toddlerhood, the bones increase in length and the muscles mature and
become stronger. The abdominal musculature is weak in early toddlerhood, resulting in a pot-bellied
appearance. The toddler appears to have a swayback along with the potbelly. Around 3 years of age, the
musculature strengthens, and the abdomen is flatter in appearance.

DEVELOPMENTAL CHANGES

Erikson defines the toddler period as a time of autonomy versus shame and doubt. It is a time of exerting
independence. Since the toddler developed a sense of trust in
infancy, he or she is ready to give up dependence and assert his or her sense of control and autonomy
(Erikson, 1963).

According to Jean Piaget (1969), toddlers move through the last two sub-stages of the first stage of cognitive
development, the sensorimotor stage, between 12 and 24 months of age. Young toddlers engage in tertiary
circular reactions and progress to mental combinations. Rather than just repeating a behavior, the toddler can
experiment with a behavior to see what happens. By 2 years of age, toddlers can use symbols to allow for
imitation. With increasing cognitive abilities, toddlers may now engage in delayed imitation. For example, they
may imitate a household task that they observed a parent doing several days ago.

The second stage of cognitive development is the preoperational stage. It occurs in children between ages 2
and 7 years. During this stage, toddlers begin to become more sophisticated with symbolic thought. The
thinking of the older toddler is far more advanced than that of the infant or young toddler, who views the
world as a series of objects. During the preoperational stage, objects begin to have characteristics that make
them unique from one another. Objects are considered large or small, a particular color or shape, or a unique
texture.

Toddlers also use symbols in dramatic play. First, they imitate life with appropriate toy objects, and then they
can substitute objects in their play. A bowl may be used to pretend to eat from, but then later it can be used
upside down on the head as a hat (Fig. 26.2). Human feelings and characteristics may also be attributed to
objects (animism) (Papalia & Feldman, 2011). See Table 26.1 for further explanation of cognitive development
in toddlerhood. Human feelings and characteristics may also be attributed to objects (animism) (Martorell,
2019). See Table 4.1 for further explanation of cognitive development in toddlerhood.
PYSCHOSOCIAL DEVELOPMENT
 The toddler is struggling for self-mastery, to learn to do for themselves what others have been doing for
them.
 They often experience ambivalence about the move from dependence to autonomy, resulting in
emotional lability.
 They may quickly change from happy and pleasant to crying and screaming.
 Exertion of independence also results in the toddler’s favorite response, “No.” The toddler will often
answer “no” even when he or she really means “yes.” This negativism—always saying “no”—is a
normal part of healthy development and is occurring because of the toddler’s attempt to assert his or
her independence.

MOTOR SKILLS
Gross motor Fine motor

 Initial walking with a “toddler” gait Progresses from holding and pinching.
 Pushing or pulling a toy Manages utensils.
 Later includes: Holds crayon.
 Running Strings a bead.
 Climbing Works a puzzle.
 Jumping Uses a touchscreen.
 Throwing a ball
 Pedaling a tricycle

NOTES: As gross motor skills are mastered and then used repeatedly, the large muscle groups in the toddler
are strengthened. The “toddler gait” is characteristic of new walkers. The toddler does not walk smoothly and
maturely. Instead, the legs are planted widely apart, toes are pointed forward, and the toddler seems to sway
from side to side while moving forward (Fig. 26.4). Often the toddler seems to speed along, pitching forward,
appearing ready to topple over at any moment. The toddler may fall often but will use outstretched arms to
catch himself or herself (parachute reflex). After about 6 months of practice walking, the toddler’s gait is
smoother, and the feet are closer together. By 3 years of age, the toddler walks in a heel-to-toe fashion like
that of adults. Toddlers often use physical actions such as running, jumping, and hitting to express their
emotions because they are only just learning to express their thoughts and feelings verbally. Table 26.2 lists
motor skill expectations in relation to age.
Fine motor skills in the toddler period are improved and perfected. Holding utensils requires some control and
agility, but even more is needed for buttoning and zipping. Adequate vision is necessary for the refinement of
new motor skills because eye–hand coordination is crucial for directing the fingers, hand, and wrist to
accomplish small muscle tasks such as fitting a puzzle piece or stringing a bead. See Table 26.2 for age
expectations for various motor skills.

SENSORY DEVELOPMENT

• Toddlers use all their senses to explore the world around them.
• Toddlers examine new items by feeling them, looking at them, shaking them to hear what sound they
make, smelling them, and placing them in their mouths.
• Toddler vision continues to progress and should be 20/50 to 20/40 in both eyes.

Depth perception also continues to mature. Hearing should be at the adult level, as infants are ordinarily born
with hearing intact. The sense of smell continues to mature, and toddlers may comment if they do not care for
the scent of something. Though taste discrimination is not completely developed, toddlers may exhibit
preferences for certain flavors of foods. The toddler is more likely to try a new food if its appearance or smell
is familiar. Lack of complete taste discrimination places the toddler at risk of accidental ingestion.

SPEECH DEVELOPMENT

Receptive language development: the ability to understand what is being said or asked.
• Typically, far more advanced than expressive language development (ability to communicate desires
and feelings)
Common occurrences
• Echolalia: repetition of words and phrases without understanding
• Telegraphic speech: speech that contains only the essential words to get the point across
• See and know Table 4.3

In other words, the toddler understands language and can follow commands far sooner than he or she can use
the words himself or herself. Language is a very important part of the toddler’s ability to organize his or her
world and make sense of it. Thoughtfully planned use of language can provide behavior guidance and
contribute to the avoidance of power struggles. Regarding expressive language development, the young
toddler begins to use short sentences and will progress to a vocabulary of 50 words by 2 years of age.
Telegraphic speech refers to speech that contains only the essential words to get the point across, much like
a telegram. Rather than “I want a cookie and milk,” the toddler might say, “Want cookie milk.” In tele-
graphic speech, the nouns and verbs are present and are verbalized in the appropriate order Early
identification and referral of children with potential speech delays is critical. If a delay is identified, early
intervention may increase the child’s potential to acquire age-appropriate receptive and expressive language
skills. At the age of 1 to 2 years, the potentially bilingual child may blend two languages—that is, parts of the
word in both languages are blended into one word.
Bilingual children often mix languages, and thus speech delay may be more difficult to assess in this
population. The bilingual child should have a command of 20 words (between both languages) by 20
months of age and should be making word combinations. If this is not the case, further investigation may be
warranted.
Emotional and Social Development
Separation
• Seeing oneself as separate from the parent
Individuation
• Forming a sense of self
• Learning to control one’s environment.
• This leads to emotional lability.
Egocentrism
• Focus on self.

Typical Toddler Behaviors

This ability to self-soothe is a function of autonomy and is viewed as a sign of a nurturing environment, rather
than, as one might suspect, one of neglect. Children also begin to learn about gender differences in the
toddler years. They observe the differences between male and female body parts if they are exposed to them.
Toddlers may question parents about these differences and may begin to explore their own genitals. Toddlers
also begin to understand and mimic social gender differences. They make observations about gender-specific
behavior dependent upon what they are exposed to. Aggressive behaviors are typically displayed during the
toddler years. Toddlers may hit, bite, or push other children and grab toys. Adults can assist the toddler in
building empathy by pointing out when someone is hurt and explaining what happened. Toddlers should
not be blamed for their impulsive behavior; rather, they should be guided toward socially acceptable
actions to foster the development of appropriate social judgment.
Offering limited choices is one way of allowing toddlers some control over their environment and helping
them establish a sense of mastery. Since toddlers naturally have a short attention span, they tend to dawdle.
As the toddlers become more self-aware, they start to develop emotions of self-consciousness such as
embarrassment and shame. The toddler will protect his or her body by resisting intrusive procedures such as
temperature or blood pressure measurement.
As toddlers become increasingly skilled at mobility, they realize that if they have the capability of leaving,
then so does the parent. As self-awareness develops and conflicts over closeness versus exploration occur,
separation anxiety may reemerge in the 18- to 24-month period (Brazelton & Sparrow, 2006). Power
struggles may escalate and distress at separating from the parent may increase. Again, a predictable routine
with an appropriate limit setting may help toddlers feel safer and more secure during this period. From the
age of 24 to 36 months, separation anxiety again eases.

Cultural Influences on Growth and Development

• Homelessness or poverty may directly influence the toddler’s ability to grow adequately as resources.
for appropriate food purchase and preparation may be lacking.
• Appropriate toys (safe ones) may also not be available in those situations.
• Food customs continue to have an impact on the child’s diet and ability to ingest appropriate nutrients.

When Toddler is Hospitalized Age-appropriate Developmental Tasks

When the toddler is hospitalized, growth and development may be altered. The toddler’s primary task is
establishing autonomy, and the toddler’s focus is mobility and language development. Hospitalization
removes most opportunities for the toddler to learn through exploration of the environment. Isolation for
contagious illness further constrains the toddler’s ability to and some control over the environment. The nurse
caring for the hospitalized toddler must use knowledge of normal growth and development to be successful in
interactions with the toddler, promote continued development, and recognize delays.

Signs of Potential Delay

Promoting the Growth and Development of toddlers through play
• Play is the major socializing medium for toddlers.
• Toddlers need 30 minutes of structured physical activity and 1 to 3 hours of unstructured physical
activity per day.
• Parents should limit television and encourage creative and physical play instead.
• Toddlers engage in parallel play (playing alongside another child) instead of cooperative play.
• Toddlers are egocentric and do not like to share.
• The short attention span of toddlers will make them change toys frequently.
• Toddlers do not need expensive toys. See Box 4.1 page 103

Promoting Safety
• Increasing mobility REQUIRES increased vigilance.
• Provide a childproof environment.
• Use a safe car seat in the back seat of the car.
• Provide a safe home environment.
• Avoid tobacco smoke exposure.
• Water safety (careful observation)
• Prevent injury.
• Prevent poisoning.

Parents should use the appropriate size and style of car seat for the child’s weight and age as required by state
law. At a minimum, toddlers should be in a rear-facing car seat with harness straps and a clip until 2 years of
age (American Academy of Pediatrics [AAP], 2019b). After the age of 2 years, a forward-facing seat may be
used. A toddler riding in a pickup truck should never ride in the cargo area or truck bed. A full rear seat in the
truck is the preferred placement for the toddler car seat. If an appropriate rear seat is unavailable, the airbag
should be disarmed, and the forward-facing car seat should be secured appropriately in the truck seat. The
lower anchor and top tether are additionally required for all forward-facing car seats manufactured since 2002
and are accommodated by motor vehicles manufactured since that time.
Environmental exposure to tobacco smoke has been associated with increased risk of respiratory disease and
infection, decreased lung function, and increased incidence of middle ear effusion and recurrent otitis media.

Safety in the Water-Drowning may occur in very small volumes of water such as a toilet, bucket, or bathtub,
as well as the obvious sites such as swimming pools and other bodies of water. Toddlers’ large heads in
relation to their body size place them at risk of toppling over into a body of water that they are inquisitive
about. Toddlers should be always supervised when in or around the water. In general, most children do not
have the physical and cognitive capabilities necessary to truly learn how to swim until 4 years of age.

To prevent injury in the home, stress the following to parents:

• Never leave a toddler unsupervised out of doors.
• Lock doors to dangerous rooms.
• Install safety gates at the top and bottom of staircases.
• Ensure that window locks are operable; if windows are left open, then secure all window screens.
• Keep pot handles on the stove turned inward, out of an inquisitive toddler’s reach.
• Teach the toddler to avoid the oven, stove, and iron.
• Keep electrical equipment, cords, and matches out of reach.
• Remove firearms from the home or keep them in a locked cabinet out of the toddler’s reach.
 • Always require the child to wear a helmet approved by the Consumer Products Safety Commission
(CPSC) when riding a wheeled toy. This starts the habit of helmet-wearing early, so it can be more
easily carried over to the bicycle-riding years of the future.
• Begin teaching the toddler about watching for cars when crossing the street, but always carry or hold
the hand of the toddler when crossing the street.
• Teach the toddler to avoid unknown animals (AAP, 2019e, 2019f).
• Discuss poison prevention in the home at each well-child visit. The AAP (2019d) recommends that
potentially poisonous substances (e.g., medications, cleaners, hair care products, car care products) be
stored out of the toddler’s teach, out of the toddler’s sight, and in a childproof, locked cabinet.
Encourage all families to take the following safety measures:
• Store all substances in original containers only.
• Never store any liquid other than soda in a soda pop bottle.
• Do not allow toddlers access to baby powder, lotion, cream, or other toddler hygiene products.
• Ensure all medications have child-safety caps.
• Do not leave within the toddler’s reach medications such as lozenges or samples that are not packaged
in safety bottles.
• Be very careful with medications that are provided in transdermal patch form.
• Do not refer to medicines as candy, as the toddler may mistake pills for candy and ingest them.
• Do not expose toddlers to hazardous vapors such as paints, cleaners, tobacco smoke, and especially
street drugs such as crack and marijuana.
• Keep “button” batteries secured and away from a toddler’s reach.
• Keep house plants off the floor, remove them from the home, or hang them or place them on a high
shelf (American Association of Poison Control Centers, 2017; AAP, 2019d).

Promoting Self-feeding
• Child-sized spoon and fork with dull tines
• Appropriate portion size, type, and texture of the food
• Seat the toddler in a highchair or at a comfortable height in a secure chair.
• Include the toddler in family mealtimes, and praise attempts at self-feeding.
• Never leave the toddler unattended while eating
• Minimize distractions during mealtime.
• Picky eater? See box 4.3 pg 109
• Food Jags
• During a food jag, the toddler may prefer only one food for several days, and then not want it for
weeks. Again, it is important for the parent to continue to offer healthy food choices during a food jog
and not give in by allowing the toddler to eat junk food (Satter, 2019).
KEY NUTRIENTS

Sleep Requirements
• Sleeps through the night and takes one daytime nap.
• 18-month-old: 13.5 hours of sleep per day
• 24-month-old: 13 hours of sleep per day
• 3-year-old: 12 hours of sleep per day
• Consistent bedtime rituals help the child prepare to sleep.
• May discontinue daytime napping around 3 years of age.

Promoting Healthy Teeth and Gums

• By 30 months of age, the toddler should have a full set of primary (“baby”) teeth.
• Parents may not be aware of the importance of preventing cavities in primary teeth since they will
eventually be replaced by permanent teeth.
• Poor oral hygiene, prolonged use of a bottle or no-spill sippy cup, lack of fluoride intake, and delayed
or absent professional dental care may all contribute to the development of dental caries.
• At age 1 year, the toddler should have his or her first dentist visit to establish the current health of the
teeth and gums.
• Public water fluoridation is a public health initiative that ensures that most children receive adequate
fluoride intake to prevent dental caries. Table 4.5 gives recommendations regarding fluoride
supplementation.
SPANKING TODDLERS (DISCIPLINE)
The toddler’s intense push for autonomy can often test a parent’s limits. The easygoing infant usually becomes
more challenging in toddlerhood. The toddler’s continual quest for new experiences often places the toddler
at risk, and his or her negativism very often taxes the parent’s patience. Toddlers younger than 18 months of
age should NEVER be spanked, as there is an increased possibility of physical injury in this age group. Also, the
infant/young toddler is not capable of linking the spanking with the undesired behavior (AAP, 2012b).

COMMON DEVELOPMENTAL CONCERNS

• Weaning to cup
• Thumb sucking and pacifiers.
• Negativism
• Temper tantrums
 • Toilet teaching
• Sibling rivalry
• Aggression and regression
• Toilet Teaching When myelinization of the spinal cord is achieved around age 2 years, the toddler can
exercise voluntary control over the sphincters. Girls may be ready for toilet teaching earlier than boys.
Toddlers are ready for toilet teaching when:

SIGNS OF TODDLER READY FOR TOILET TRAINING

• Regular bowel movement

• Expresses knowledge of the need to defecate or urinate.
• The diaper is not always wet.
• The toddler is willing to follow instructions.
• The toddler walks well alone and can pull down pants.
• The toddler follows the caregiver to the bathroom.
• The toddler climbs onto a potty chair or toilet.

NEGATIVISM
• As the toddler separates from the parent, recognizes his or her own individuality, and exerts
autonomy, negativism abounds.
• Parents should understand that this negativism is a normal developmental occurrence and not
necessarily deliberate defiance (though that also occurs).
Avoid asking yes-or-no questions, as the toddler’s usual response will be “no,” whether he or she means it or
not. Offering the child simple choices will give the toddler a sense of control. The parent should not ask the
toddler if he or she “wants” to do something if there is actually no choice. “Do you want to use the red cup or
the blue cup?” is more appropriate than “Do you want your milk now?” When it is time to go outside, don’t
ask, “Do you want to put your shoes on?” Instead, state in a matter-of-fact tone that shoes must be worn
outside and give the toddler a choice of type of shoe or color of socks.

TEMPER TANTRUMS
• Temper tantrums are a natural result of the frustration that toddlers experience.
• Toddlers are eager to explore new things, but their efforts are often thwarted (usually for safety
reasons).
The temper tantrum may be manifested as screaming and crying or a full-blown episode in which the toddler
throws himself or herself on the floor kicking, screaming, and pounding, perhaps even holding her breath.
Fatigue or hunger may limit the toddler’s coping abilities and promote negative behavior and temper tantrums
(Pendley, 2012). Although tantrums are annoying to parents and caregivers, they are a normal part of the
toddler’s quest for independence. As toddlers mature, they become better able to child is safe during a
tantrum. Physical punishment will probably just prolong the tantrum and in fact produce more intense
negative behavior. If the tantrum occurs in public, it may be necessary for the parent to immobilize the child
with a big bear hug and use a calm voice to soothe the toddler. It is very important for parents to model self-
control. Since toddlers’ tantrums most often result from frustration, the role-modeled behavior of self-control
helps to teach toddlers to control their temper when they can’t get what they want.

Thumb sucking and pacifiers

• Toddlers may calm themselves in a stressful situation by thumb-sucking or sucking on a pacifier.
 • Opinions about thumb and finger sucking and pacifier use are significantly affected by family history
and culture.
• For most children, there is no need to worry about a sucking habit until it is time for the permanent
teeth to erupt.
Prolonged and frequent sucking in the withdrawn child is more likely to yield changes to the tooth and jaw
structure than sucking which is primarily used for self-soothing. Parents must sort through their own feelings
about thumb sucking and pacifier use and then decide how they want to handle the habit. To ensure safety
with pacifier use:Use only one-piece pacifiers. Replace worn pacifiers with new ones. Never tie a pacifier
around a toddler’s neck. Parents may want to limit thumb sucking and pacifier use to bedtime, in the car, and
in stressful situations. The parent should calmly discuss these limits with the toddler and then remain
consistent about enforcing them (Sexton & Natale, 2009).

Regression
• Some toddlers experience regression during a stressful event (e.g., the birth of a sibling, or
hospitalization).
• Stress in a toddler’s life affects his or her ability to master new developmental tasks.
• During regression, the toddler may want to go back to an earlier stage.

He or she may desire a bottle or pacifier long ago forgotten. The toddler may stop displaying previously
achieved language or motor skills. A significant stress in the toddler’s life may also disrupt the toilet teaching
process (toilet teaching may not be achieved near the time a sibling is born). When regression occurs, parents
should ignore the regressive behavior and offer praise for age-appropriate behavior or attainment of skills.

MINIMIZING SIBLING RIVALRY

• Keep the toddler’s routine as close to normal as possible.
• Minimize other changes in the household, if possible
• Spend individual time with the toddler on a daily basis.
• Involve the toddler in the care of the baby.