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Growth and Development of the Toddler

Lillian L. Toren RN MS MSN Learning Outcomes Describe physical characteristics common to toddlers Describe psychosocial and cognitive development using theories of Erikson and Piaget Describe the role of play during the toddler years Discuss the role of the pediatric nurse when caring for a hospitalized toddler Introduction AGES 1 TO 3 During this period, there is change from an immobile and pre verbal infant who is dependent on caregivers, to a walking, talking child with a growing sense of autonomy Toddlers display independence and negativism There is pride in new found accomplishments There is an intense exploration of the environment as the toddler attempts to find out how things work Challenge for parents encourage autonomy while keeping a curious toddler safe Physical Growth and Development 1017 Infancy is a time of intense growth and development During toddler years, physical growth SLOWED and acquisition of new motor skills ACCELERATE There is refinement of motor skills There is continued cognitive growth and acquisition of language skills Body proportions change legs are longer, head is smaller Toddlers have a pot belly appearance- WHY? ABD ARE WEAK, THEY PROTRUDE WHILE GROWING THEY BECOME LEAN. Toddlers stand with feet apart to provide a wide base of support Height Grows about 3 inches per year-DNTK TODDLER GROWTH IN THE LEGS--------INFANT MORE IN TRUNK

By age 2, toddler is about half of their adult height

Weight Average weight gain is 2 to 4 pounds per year By age 2 , birth weight has quadrupled Head and Chest Circumference
ANTERIOR FONTANEL CLOSES BETWEEN 12-18 MONTHS - NTK

About age 12 months, head and chest circumference are equal After age of 1 year, chest circumference is greater than head circumference After age 2 years, chest circumference is greater than abdominal circumference Maturation of Systems-1018 Neurologic System Brain growth continues brain reaches 90% of adult size by age 2 years Myelinization of brain and spinal cord continues Sensory Hearing, smell, taste and touch is well developed Taste preferences develop less likely to try new foods than infant All senses are used to explore the environment Vision Visual acuity 20 /40 Binocular vision well developed STRABISMUS needs professional evaluation and intervention can lead to amblyopia -3,4,6 CRANIAL NERVES Depth perception continues to develop but falls are still common as the toddler is uncoordinated Cardiovascular System Heart rate slows (110 beats /minute to 90 beats /minute) BP increases (99 /64 mmHg) Blood vessels are close to the skin surface easily palpable Thermoregulation with moderate temperature changes, toddlers can maintain body temperature Respiratory System

2 Respiratory rate slows respirations are mostly abdominalUNTIL AGE 6 Respiratory structures continue to grow and mature Alveoli continue to increase in number reaches adult number about age 7 Trachea and lower airways continue to grow but still small compared with an adult- TODDLERS MORE RISKS FOR ASPIRATION Tonsils and adenoids are large Eustachian tubes are relatively short and straight- RISK FOR middle ear infections Gastrointestinal System Stomach capacity increases child can consume 3 meals per day-AND 2 SNACKS Digestive process almost complete (some hard to digest foods may pass whole) Stools frequency decrease (1 2 per day) Stomach secretions become more acidic (a protective function) Genitourinary System Bladder and kidney reach adult levels by age 2 years Bladder capacity increases able to retain urine for increased periods of time Urethra remains short susceptible to urinary tract infections Physiologic control of urethral and anal sphincters about 18 to 24 monthsTHEY CAN NOW CONCENTRATE URINE Immunologic System Phagocytosis more effective than in infant Antibody production becomes mature Passive immunity via intrauterine life is no longer effective Musculoskeletal System Bones increase in length Muscles mature and become stronger Weak abdominal muscles result in pot belly appearance About age 3 years, abdominal musculature strengthens and abdomen is flatter in appearance TODDLERS ARE LONG AND LEAN, AGE 2 ORGANS BECOME MATURE Gross Motor Development 1025 12 13 months, Walks independently using a wide base gate 15 months, Walks along well, creeps up stairs 18 months, Begins to run falls easily, loves push pull toys, jumps in place with both feet 24 months, Walks up and down stairs alone both feet on same step 2 years, Jumps with both feet, climbs onto and down from furniture without assistance 3 years, Climbs well, pedals tricycle, runs easily, walks up stairs with alternate feet, down stairs with both feet, bends over without falling Fine Motor Development o 12 months, Grasps small objects, not able to release it at will o 12 15 months, Feeds self finger foods- CHEERIOS, SHREAD CHICKEN, MUSHY CARROTS o 15 months, Uses a cup well, able to release small objects, stacks two blocks, puts small pellets into small bottle o 18 months, Rotates a spoon and brings it to mouth, stacks 3 or 4 blocks, turns pages in a book (2 or 3 at a time) o 2 years, Stacks 6 7 blocks, scribbles, points, begins to turn knobs o 3 years, Undresses self, copies circle, stacks 9 or 10 blocks, screws, unscrews lids, turns pages one at a time Psychosocial Development Erikson 1019
TODDLER IS IN ERIKSONS AUTONOMY VS SHAME AND DOUBT. INFANT IS IN ERIKSONS TRUST VS MISTRUST.

Autonomy vs Shame and Doubt Ages 1 to 3 years Increased ability to control self and environment Practices and acquires new physical skills, developing autonomy Autonomy symbolizes independence by controlling body secretions, saying no when asked to do something and directing motor activity- THEY LEARNED THE WORD NO. A healthy level of autonomy is achieved when parents are able to

3 encourage independence while still maintaining consistency and sound rules for safety. During this stage the toddler learns independence and begins to problem solve
IN AUTOMONOMY VS SHAME/DOUBT

If successful, develops self confidence and will power - If unsuccessful, develops doubt about their abilities In the toddlers quest for autonomy, two important characteristics are expressed: Negativism and Ritualistic Behavior 1028 Negativism ALSO COMES DWODDLING This is the persistent negative response to requests NO! This is a normal part of healthy development This is the toddlers attempt to assert their independence Toddlers experience ambivalence about the move from dependence to autonomy This results in emotional labiality To exert this independence, the toddler uses the word no, even when they mean yes Ritualism Ritualism is necessary to maintain sameness and reliability it is a sense of comfort Without comfortable rituals, there is little opportunity to exert autonomy Ritualism allows the toddler to venture out into the world feeling secure and knowing that familiar people, places and routines still exist Without rituals, the world would be too scary, thus dependency and regression occur ASK THE PARENT WHAT THEY Cognitive Development 1019
DO AT HOME FOR RITUALS.

Thus, toddler tries out actions to learn results and find out how the world works Toddler turns objects in all directions, places them in the mouth, uses them for banging and inserts them into containers (and orifices) In this way, they explore their qualities and uses The toddler can pretend and imitate behavior they observe in their environment Mental Combinations (18 to 24 months) Language allows the toddler to think about events and objects before they occur Object permanence develops as toddler actively searches for objects out of viewPre operational Stage (2 to 7 years)
IN THE PREOP STAGE THE CHILD BEGINS TO THINK LOGICALLY WITH SYMOOLS AND ASSIMILATE THEY ID WITH THE SAME SEX PARENT.

Sensorimotor Stage until 2 years, then Pre Operational Stage until 7 years Tertiary Circular Reactions (12 to 18 months) Curiosity, experimentation and exploration predominate this period

In this stage, the young toddler thinks by using words as symbols Logic is not well developed There are 2 substages Pre conceptual ( 2 to 4 years) Intuitive (4 to 7 years) In these 2 substages, the child is still not capable of logical thinking However due to the increased ability to use words and actions together, the child is increasingly able to connect cognitively with the world Toddlers begin to use assimilation to change a situation to fit their thoughts As a result of cognitive learning and preoperational thought, several developmental milestones occur Imitation has a deeper meaning and understanding as the child interacts with the environment helps with household activities Begins to identify with parent of the same sex AGE 3, CONCEPT OF TIME Concept of time Sense of time in relationship to anticipation, memory and a limited ability for delayed gratification Has limited attention span, toddler has a sense of immediacy and concern for the present

4 Age 2 to 3 years, begin to use preoperational thought; increasing use of words as symbols; begins to ask why and how Egocentric speech P 1021 Repeats words and sounds for pleasure of hearing oneself; this is not intended for communication Socialized speech Before age 3, speech is directed at self fulfillment, i.e. me do, me come, with the expectation that others understand their verbal messages TO GET SOMETHING FOR THEMSELVES After age 3, speech is still egocentric as communication is about themselves to others EGOCENTRIC THOUGHT The inability to see a situation from another's perspective JUST PAST AGE 3 Global organization Changing only one part of the whole changes the whole-doing one step different throws them all off track or routine. Centration Focusing on one aspect rather than considering all possible alternatives ANIMISM Attributing life like qualities to inanimate objectsWHEN THEY TRIP THEY SAY BAD STEP FOR EX. MAY CAUSE SLEEP ISSUES Nursing application for hospitalized child Ask about rituals, potty training , THEY MAY REGRESS IN THE HOSPITAL. THEY REGRESS TO WHERE THEY R COMFORTABLE. Accept regression as normal-- LOTS OF PRAISE AND COMFORT, AFTER MED ADM. Permit help with ADLs, i.e. dress and feed self Ensure safe environment- NIGHT LITE TO KEEP THEM FEELING SAFE Encourage opportunities to manipulate objects If immobilized for a procedure, provide explanations and comfort proceed quickly Social Development 1. Separation /Individuation This is differentiation of self from significant others Separation The toddlers emergence from seeing self as symbiotic with mother Individuation The toddlers individual characteristics as they interact with the environment Separation anxiety is observed when young children (6 30 months) are separated from familiar people and surroundings This reaches a peak around 15 months The older toddler begins to loose some resistance to separation However, they become more concerned about their parent's whereabouts They are able to venture away for brief periods knowing that parents will be there when they return The older toddler begins to become less fearful of strangers when with their parents When left alone with strangers, reactions typically are fear, anxiety, crying, withdrawal, restlessness, passivity, regression Rituals and a transitional object(TOY, BLANKET) helps to comfort and provide security Stages of Separation Anxiety Protest Child appears sad, agitated, angry, desperately watches for parents to return Despair Child appears sad, hopeless, withdrawn Acts ambivalent when parents return Detachment Child appears happy, interested in environment, becomes attached to hospital staff members May ignore parents when they visit (this becomes a protective mechanism for them) ****Nursing interventions related to separation anxiety******** The goal is to preserve the childs trust Reassure child that parents will return Encourage rooming in Have parents leave a personal item i.e. picture, transitional object When possible, maintain usual routine and rituals When possible, allow choices

5 Communication and Language 1023 Toddlers imitate words, speech intonations and social situations they observe The ability to understand (receptive language) is more developed than the ability to speak (expressive language) i.e. They understand more than they can say- BABY TALK IS NOT GOOD TO USE By 1 year, one word sentences One word may be used to represent an entire phrase or idea (holophrase) By 2 years, know 300 words Use 2 to 3 word sentences Frequently repeats naming of objects helps to learn appropriate words for objects By 3 years, vocabulary about 1000 words 3 to 4 word sentences Can say name, age and gender Uses pronouns and plurals Play 1023 Play is the work of the child They learn what they are capable of They develop skills necessary to interact with others Parallel play This is play side by side with similar objects with minimal to no interaction with the other child Toddlers enjoy toys they can play with by themselves Toys they can control, giving them a sense of power in manipulation, an expression of autonomy These toys include---Trucks they can make go Push pull toys (a waddling duck) Rocking horses they can ride Pegs they can pound Blocks they can stack- IMP TO THEM Toy telephone POTTY TRAINING IS a major task of toddlerhood THIS IS DONE ACCORDING TO THE CHILDS SCHEDULE This is an individualized task for each child It should begin and be completed according to the childs ability to accomplish it not according to a schedule Before beginning, toddlers should reach some important developmental levels--------------A. Physiologic: Ability to have control of urethral and rectal sphincters B. Motor Skills: Gross motor skills of sitting, walking, squatting Fine motor skills to remove clothing C. Cognitive: Recognizes urge to urinate or defecate Communication skills to indicate when wet or has urge to urinate or defecate. A cognitive understanding of what it means to hold urine and stool then release them in a certain place at a certain time. Desire to delay immediate gratification for a more socially accepted action.
POTTY TRAINING HELPS UNDERSTAND DELAYED GRATIFICATION.

D. Other: Parent to recognize childs level of readiness Willing to invest time required for this task Absence of stress or change in the childs life Helpful Ideas: Free standing potty chair so toddlers feet are on the floor Limit time, no more than 10 minutes Stay with child Practice sanitary habits (wiping front to back and washing hands with soap) Transition to portable seat attached to toilet seat, use small bench for feet to rest Alternative is to have toddler sit facing toilet tank Dress child in clothes they can easily remove Use words the child can understand Always praise child, whether or not they are successful- BY THREE THEY SHOULD ACHIEVE DAYTIME DRYNESS.BOYS MAY BE A LITTLE LATER. Sibling Rivalry Toddlers do not like change An addition to the family constitutes change, NOT THE NEW BABY

6 Sibling rivalry is the natural jealousy and resentment of the toddler toward a new child It is not the infant the toddler dislikes, rather the changes that occur, especially separation from mom during birth Helpful Ideas: Preparation via sibling class and /or storybook Encourage supervised helping with new baby, OR BUY A DOLL, TELL M/D NOT TO TELL THE TODDLER THIS IS A PLAYMATE. Expect regressive behavior Spend uninterrupted alone time with the toddler Temper Tantrums 1028 These are a natural result of frustration They occur more when the toddler is hungry, tired or frustratedLOOK FOR THESE THINGS, MAY BE ABLE TO CONTROL. Some of their frustration may come from lack of language skills to express themselves Toddlers are not being difficult on purpose They need time to learn rules and regulations they want to explore new things, but their efforts are often hindered due to safety concerns Note behavioral cues Is toddler, hungry, tired, frustrated Intervening early with an activity change may prevent a tantrum use distraction, refocusing or remove them from the situation Helpful Ideas: Ignore behavior ensure child is safe Be calm and supportive, use a calm voice Be consistent and set clear and realistic limits on behavior- BE CLEAR If in a public area, may need to physically move the child to a different environment Regression 1029 This is a retreat from present pattern of functioning to a past level of behavior which is often more comfortable Occurs most often when stressed an attempt to cope by reverting to a pattern of behavior that was successful in an earlier stage of development COMFORTABLE MAY HAPPEN IN THE HOSPITAL Helpful Ideas: Ignore regressive behavior and praise existing pattern of appropriate behavior Spiritual Development 1021 Parallels cognitive development Strong influence from family and environment Family values, beliefs, customs influence childs perception of their spiritual self Learn about G-d via words and actions of family Have a vague idea of G-d and rituals (due to their immature cognition) Routines such as saying prayers can be comforting Near the end of toddlerhood (pre operational thought), religious teaching such as reward and punishment may influence behavior Moral Development Toddlers are concrete thinkers GOOD OR BAD They understand that some behaviors are good /bad but not why? They identify with good /bad, right /wrong by virtue of whether or not the behavior is rewarded or punished Body Image 1022 Toddlers have poorly defined body boundaries Intrusive experiences are threatening Begin to explore their own body touching parts that are pleasurable Masturbation is common parental reaction influences the childs own attitude; its best when parents are accepting rather than critical /negative Sex role differentiation begins to be obvious Begins to identify with same sex parent By age 2, recognition of gender differences By age 3, gender identity is developed Nutrition -1030

7 Between 12 to 18 months, growth slows Around 18 months, Physiologic anorexia decreased nutritional need with a decreased appetite Protein and caloric requirements are still high to meet demands for tissue growth and increased activity level Offer balanced diet, nutritious snacks Select foods that are easily chewed Toddlers have small airways, prevent aspiration
MILK LACKS IRON AND VIT C LIMIT MILK to 16 24 ounces /day, to

The experience should be non threatening Infants /toddlers should not have a bottle with milk or juice at bedtime
TODDLERS OR INFANTS SHOULD NOT HAVE MILK OR JUICE AT BEDTIME. WATER ONLY THIS IS BC OF DENTAL CARIES.

prevent iron deficiency anemia---1 pint/day----milk doesnt have vit c or iron. Limit long meals toddlers not able to sit for a long time without becoming restless Toddlers prefer to feed themselves finger foods; expect a mess Easily overwhelmed by large portions Rule of thumb One tablespoon /year for each food served Toddlers are fussy eaters strong taste preferences Generally, less spicy, bland foods well tolerated Food jags May eat same foods for days at a time Imitates family members food preferences Ritualism use same dish, cup, spoon and seat at dining table Dental Hygiene By age 3 years, 20 deciduous teeth When infants starts to teethe, parents should wipe teeth with soft cloth after eating With more teeth, use a small, soft bristled brush Some toddlers prefer only water not toothpaste Fluoride supplements for infant over 6 months where water is not treated For best results, give on empty stomach, wait 30 minutes before any intake, if possible, fluoride to remain in mouth for 30 seconds Oral examination by practitioner about age 2

Health Promotion /Health Maintenance Well child visits continue with anticipatory guidance Immunizations 6 18 months: Hepatitis B; IPV 12 15 months: Hib; PCV; MMR; Varicella 15 18 months: DTaP 12 months 6 years: Influenza (yearly) 12 months 2 years: Hepatitis A Injury Prevention Car Seat: Position seat upright and facing forward when 1 year /20 pounds
DO NOT PUT TODDLERS NAME ON BACKPACK.

Drowning Burns TURN HEAT DOWN TO 120 DEG. Poisoning Falls Choking and Suffocation Toy Safety Bodily Damage