toddler age range
12 months through 36 months
Toddler – Physical Development
Physical growth – 5 lb./yr weight 3 in/yr Ht
Physiologic anorexia
Anterior fontanel closes 12 to 18 months
Achieves 50% of adult height by 2 years
Toddler – Gross Motor
Walking by 15 months
Climbing on anything
Removing clothing
Stoops and recovers
Toddler – Gross Motor
By 18 months
Runs clumsily, falls often
Walks up stairs with hand held
Jumps in place with both feet
Toddler – 24 mo – Gross Motor
Throws ball over hand. Kicks ball.
Goes up and down stairs with 2 feet on each step
Toddler – Gross Motor
By 30 months –
Jumps from chair, steps, anything
Stands on one foot momentarily
Fine Motor
Scribbles
Can use a spoon and toothbrush, but messy
2 yr. wash and dry hands
Toddler- Negativism and Ritualism
Really want to be an adult
Ask them to do something and they will say “no”
Ask them to help you the adult do something they are doing, and you will get a Big Yes
Critical Tasks of Toddler Period
Recognition of self as a separate person with own will
Control of impulses and acquisition of socially acceptable ways to communicate wants and needs
Control of elimination
Toleration of separation from parent
Preoperational Thinking
Egocentrism – views everything in relation to self and is unable to consider another’s point of view
Animism– Believes that inert objects are alive and have wills of their own
Preoperational
Irreversibility – Cannot see a process in reverse order. Can not follow a line of reasoning back to its beginning.
Magical thought – wishing something will make it happen
Believe that their thoughts are all powerful
Preoperational
Centration – Tends to focus on one aspect of an experience. May have difficulty putting together a puzzle. Focuses on dominant characteristics of an object
Moral and Spiritual
Kohlberg
Preconventional or Premoral phase
Whether an action is good or bad depends on whether it is rewarded or punished
Fowler
Spirituality is based on images and imagination
Language/communication
15 – 18 mo – Putting two words together (25% intelligible)
Understands simple directions
2 – 3 word phrases by 2 years (50% intelligible)
3 – 4 word sentences by 3 years (75% intelligible)
Own first and last name can be stated by 2 ½ to 3 years
Communicating with the Toddler
Ask parents what his words for things like urination are
Tell exactly what you are going to do just before you are going to do it
A combination of words and gestures for expressing wants–Holographic speech
Are learning to name body parts
Concerned about body
Boo boos
Male vs. female
Well-Child Visit
Blood Lead Level at 1 year & 2 year visit
Hgb/Hct
Vision – cover, uncover test
Parenting Issues – Toddler years
Discipline
Toilet Training
Temper Tantrums
Discipline
Consistent limits
Positive reinforcement
Immediate consequences
Redirection or distractions
Time outs: 1 minute per year of age
Readiness for toilet training
Can remove own clothing
Is willing to let go of a toy when asked
Has been walking well for one year
Notices when diaper is wet
Communicates need to go to bathroom
Wants to please parent by staying dry
Family not under major stressors
Temper Tantrums
Limited language leads to frustration
Anticipate
Inconsistent parental practices increase frequency of tantrums
Isolate safely and ignore
Anticipatory Teaching
Regular meal times with utensils that fit, with family
Soft toothbrush, non-fluoride toothpaste
Sleep about 12 – 14 hr/day, 1 nap
Limit TV viewing to < 1 hr day
Bedtime routine
Nutrition
Toddlers have the highest number of taste buds and the higher degree of taste sensitivity.
Eating jags
1 Tbsp of solid food per year of age
Ritualism = regular meal times
Whole milk at 1 year – 24 – 30 oz/day
100% juice – 4 – 6 oz/day – Cup only
Domestic mimicry –Symbolic Play
Imitating parent of same sex in household tasks – domestic mimicry
Deferred imitation is imitating the parent after they have left their sight
Toddler – Age Appropriate Toys
Noise-making, push-pull toys, riding toys, work bench, toy hammers, musical anything, drums, pots and pans
blocks, puzzles with very few large pieces
finger paints, crayons, clay
dolls/stuffed animals
Toy telephones
Storybooks with pictures
Acetaminophen Poisoning
Most common accidental drug poisoning in children
Toxic dose is 150mg/kg or greater in children
Multiple formulation and concentrations make chronic acetaminophen toxicity a significant problem
Acetaminophen Poisoning
Treatment:
Antidote N-acetylcysteine (Mucomyst) can usually be given orally
Dilute with fruit juice or soda
Give loading dose, then 17 maintenance doses
“The US Food and Drug Administration (FDA) issued an important warning related to the safety of acetaminophen. The FDA recommended that healthcare professionals discontinue prescribing and dispensing prescription combination drug products that contain more than 325 mg of acetaminophen per tablet, capsule, or other dosing formulations.”
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Lead Blood Levels
Blood test done if infant is at risk at any time
Universal Lead Serum Test is done at 1 year and 2 years
Lead Poisoning
Children who are iron deficient absorb lead more readily than those with sufficient iron stores
Lead interferes with the binding of iron onto the heme molecule
Long-term neurocognitive signs of lead poisoning
Developmental delays
Lowered IQ (intelligence quotient)
Reading skill deficits
Visual-spatial problems
Visual-motor problems
Learning disabilities
Hospitalization and Toddler
Interferes with the developmental task of developing a sense of control and autonomy
Major Fears
Loss of Control
Separation
Nursing supportive Interventions for Toddler and Family
Minimize separation from parents
Explain and maintain consistent limits
Simple brief explanations
Ask about home routines & rituals
Nursing supportive interventions for Toddler and Family
Teach parents to explain their plans to the child (“I will be back after your nap.”)
Provide sensory play (water play, finger painting)
Trips to the playroom – mobility is very important to their development
Expect regression
Normal Vital Signs for Toddlers
Heart Rate: 90 – 140
Respiratory Rate: 24 – 40
Systolic BP: 80 – 112
Diastolic BP: 50 – 80
Preschool – 3 yr – 6 yr
A Powerhouse of gross motor activity.
Play and fantasy are important.
Has a fear of abandonment.
Physical Development
Growth still about the same as in the toddler period.
5 lb/yr (2.25kg) Weight
Average wt. of 3 yr. old is 32 lb. ( 14 – 15 kg)
2 -3 inches Ht per year
Teeth – now at age 3 has all 20 primary teeth
May have achieved night time bowel and bladder control
Preschool Gross Motor
Runs well
A 3 year old can ride a tricycle
Hops on one foot at about 4 yr
Walks up and down stairs well
Preschool Fine Motor
Uses scissors at 4 years
Ties shoelaces at 5 years
Washes hands
Scribbles and draws. Important for learning to read.
Psychosocial
Starting to develop an ability to separate from parents for a while
Preschoolers much more sociable and willing to please than toddlers
Kohlberg
Preschoolers: Premoral (or Preconventional) before the age of 4yr – based on punishment or reward
Have a concrete sense of justice and fairness
Language
Uses 3 and 4 word sentences.
(the age + 1 = # of words in sentence)
3yr old + 1 = 4 word sentences
Vocabulary increases from 300 words at 2 yr of age to 2100 word at 5 yr
Bilingual children reach language milestones at the same time as monolinguals
By 4 yr should be counting and naming colors
Speech
Most critical period for speech development occurs between 2 and 4 years
Stammer as they try to say a word they are already thinking of – developmental stuttering
Communication with Preschooler
Simple sentences
Careful with what words you use
Use play in explaining
Starting to speak in full sentences
Social/Emotional
Imaginary playmates
Play very important
Aggressiveness at 4 years is replaced by more independence at 5 years.
Sex education
Sexual curiosity
Masturbation is normal
Interested in anatomical differences
Find out what children know and think
Be honest, use correct names for anatomical parts
Development of gender identification
Gender identification – identify with same sex parent while developing strong attachments to opposite sex parent
Gender identification occurs around 3 yr.
Therapeutic play
Provides an emotional outlet
Pre-op teaching
Help reduce fear
Preschooler Toys
3 year old – Rides tricycle– needs helmet
4 year old – climbs and jumps and skips
5 year old – skips on alternate feet; ties shoes; beginning of cooperative play
Imitative of adult patterns and roles.
Offer playground materials, housekeeping toys, coloring books,
Toys for the hospitalized preschooler
Coloring books Puzzles Cutting and Pasting Dolls Building blocks Clay Pretend medical equipment
Well child visit for Preschooler
Hgb done between 3 & 5 yr
Normal: Hgb 11.5 – 14.5 g/dL
Lead screening if not done at 1 & 2 yr. or at risk
Urinalysis – once between 15 mo. & 5 yr
Bedwetting – if have been dry at night, then start wetting bed again, usually due to UTI
Anticipatory Teaching
Sexual curiosity, anatomic explorations, masturbation common and normal
Sleep – 10 – 12 hours in 24 hour period
Sleep problems common because of active imagination
Sleep problems
Nightmares-
Scarey dream followed by full waking
Occurs in REM sleep in second half of night
Crying and aware of presence of another person
Professional counseling for recurrent nightmares
Night Terrors-
Partial arousal from very deep sleep
Non-REM sleep in first few hours of sleep
Screaming, not aware of another person’s presence
Night terrors normal, and no intervention needed
Nightmares =
counciling
Night Terrors
No counciling
Limit TV watching to 1 – 2 hours
Extensive television viewing is associated with sleep problems in preschoolers
Vision Screening
Vision screening begins at 3 years
“Tumbling E” or Lea symbol chart
Amblyopia needs to be detected and treated before the age of 4yr.
Parenting Issues – Preschool
Balancing the child’s need to develop independence and initiative with the need to set limits
Ignore bad behavior & reward good behavior
Time Out – 1 minute per year of age
Safety
Water – Highest risk for drowning is in preschool period
Fire – stop,drop,roll
Sports Safety– helmets
Car Seat – Keep your child rear-facing as long as possible. Should be rear-facing till wt. and ht. limit of car seat is reached.
Booster seat when outgrows are seat
Prevention of sex abuse
Teaching children normal, healthy boundaries of their bodies
Tell someone
Diet and Nutrition
Milk 2% is still 2 – 3 cups/day
Juice (100%) still limit 4 – 6 oz /day
Calcium needs for children 1 – 3 yr is 500mg/day
and for children 4 – 8 yr is
800 mg/day
Dental
First dental exam at 3 yr.
Brush teeth 2 x day
See dentist every 6 months
Fluoride supplementation
The preschool child and hospitalization
Major fears
Bodily injury and being abandoned.
Fear of anything that he views as a hostile invasion of his body.
Hospitalization & Preschooler
Follow home routines
Parents close and involved
Tell child that he did not cause the illness
Accept regression and explain to parents
Normal Vital Signs for Preschoolers
Heart Rate: 80 – 110
Respiratory Rate: 22 – 34
Systolic BP: 82 – 110
Diastolic BP: 50 – 78
School Age
6 – 12 year
Physical
Slow steady growth
- -Wt. gain: 5 ½ lb/yr
- –Ht. : 2 in/yr
Growth spurt at 10 – 12 hr for girls at the onset of puberty
Two years later for boys around 12 – 14yr
Physical
Enlarged tonsils and adenoids are common during these years and are not always an indication of illness.
IgA & IgG levels are at adult levels at 10 yr.
Motor
Constant activity – Gross motor
Musical instruments & Eye-hand coordination – Fine motor development
Sensory
Eyes fully developed by 7 yr.
Growth spurt in eyes leads to myopia
Yearly visual screenings – Using Snellen chart
School Age Child
Erikson’s Stage is
Industry vs. Inferiority
Mastering useful skills and doing them well are important
Competence
School Age Child
Egocentric thinking is replaced by social awareness of others
Socialization with peers becomes important
Parents still have a strong influence
Relative period of calm
Cognitive
Concrete Operations:
- Reversibility
- Conservation - Milk glasses or 1 lb of rocks/feathers
- Classification & Logic
- Humor
Spiritual Development
Follows family’s religious practices
Religious concepts must be presented in concrete terms
God is viewed in human terms
Moral Development (Kohlberg)
Conventional Stage of Moral Development
–Younger school age children obey authority
–And follow rules
–Views are black and white
Anticipatory Guidance
Resistant to baths and showers, brushing teeth, everything
Then showers all the time
Sleep – Reduces from 12 hr at 6yr to 9 or 10 hr for a 12 year old
Promoting Self Esteem
Give child household responsibilities
Emphasize child’s strengths
Do not do their homework or science project for them
Allow children to make mistakes
Consistency
Health promotion
Need a health care visit about every 2 years
Scoliosis screening
Nutrition – There is increase in appetite
What did you eat for breakfast, for lunch
The vitamins most often consumed in less than appropriate amounts by preschool and school-age children are:
Vitamin A
Vitamin C
Vitamin B6
Vitamin B12
Obesity
Genetic, cultural, environmental, socioeconomic
Unstructured meal, fast-food
Lack of exercise
Food as reward
Limit TV to 2 hr or less a day
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One variable that did modify the interaction between violent video games, aggressive cognitions, and aggressive behaviors was age.
Games had a greater impact on aggressive cognitions among younger children.
Dental
Loss of primary teeth and eruption of permanent teeth – will replace about 4 teeth per year until 12 years
Fluoride toothpaste, flossing
Dental sealants
Mouth protectors
Dangers of smokeless tobacco
Safety
Car Seats Firm limits and rules Helmets, knee pads, etc. Water safety Self care children Gun safety
Car Seats – 8 – 12 years
Keep child in a booster seat until big enough to fit seatbelt. Seat belt fits properly when the lap belt lies snugly across the upper thighs, not the stomach. The shoulder belt should lie snug across the shoulder and chest and not cross the neck or face.
Firearm Safety
Avoid having firearms in the house
Lock ammunition and firearm in separate cabinets
Talk about firearms – what to do if you find a gun at school or at a friend’s house
Leading cause of death in children 5 – 14yr
- Accidents – Most accidents occur between 3p & 6pm
- Malignant neoplasms
- Congenital anomalies
- Assault/homicide
- Suicide/self-harm
Hospitalization of the school aged child
FEARS
Loss of control
Body injury
Failure to live up to expectations
Death
- Provide choices
- Provide concrete explanations
- Contact with peers
- Emphasize normal things the child
By age 9 or 10 years, children have an adult concept of death. They realize that it is inevitable, universal, and irreversible.
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Toys for school-age child
Board games Card games Hobbies, collections Puzzles Video games
Communicating with School Age
Audiovisual aids work well
Drawing
Drawing is a very valuable form of communication
Conversation
Ask about school and friends
Expanding vocabulary
Pages 125 & 126
School-age
Cooperative play and sports
Repair, building, mechanical activities
Table games
Adolescence 12 - 18 yr
Developing a sense of identity.
Developing independence from family.
Establishing meaningful relationships with peers
Physical
Rapid – Peak height velocity (PHV)
Girls – 12 yr
Boys – 14 yr
Growth in ht for girls ceases about 2 – 2 ½ yr after menarche
Girls – growth and sexual maturation occur about 2 years earlier than boys
——Increase fat deposits
Boys –Muscle mass
Gynecomastia
May occur with normal achievement of male puberty and resolves within 1 year
Can be caused by anabolic steroid use or endocrine disorders
Testosterone supplementation may aggravate gynecomastia
Early Adolescence
11 – 14 years
Characterized primarily by the changes in puberty
Preoccupied with rapid body changes
Decline in self-esteem
Imaginary audience, Personal fable
Middle Adolescence
15 – 17 years
Conformity
46.7% sexual intercourse experience
Peer orientation of peak importance, and acceptance by peers is total focus
Abstract thinking – Idealistic, political & social concerns
Late adolescence
18 – 21 yr
Idealistic
Emancipation
Transition into adulthood
Spiritual
Beliefs become more abstract
Kohlberg stage 4 and 5
Question family’s values and religion
Cognitive
New findings show that the greatest changes to the parts of the brain that are responsible for functions such as self-control, judgment, emotions, and organization occur between puberty and adulthood.
Overproduction, then pruning of neurons in response to puberty.
Leading cause of death 15 – 19 yr.
- Accidents – 40% of all teen deaths is the U.S. are the result of motor vehicle accidents
- Homicide
- Suicide
- Malignant neoplasms
- Heart diseases
Parenting Issues
Discipline – focus on encouraging teen to make decisions and understand consequences
Save battles for important things
Communicating with adolescents
Ensure confidentiality and privacy
Interview alone. And first. May interview parents afterwards.
Adolescents will share more information when it is gathered during a casual conversation.
Explain limits of confidentiality (abuse,suicide)
Open ended questions – Direct questions may illicit little information
Adolescent communication cont’
In education, give details, include audiovisual material
Never talk down to
Able to comprehend adult concepts.
When teaching adolescents, the focus on the here and now – “How will this affect me today?”
Warning Signs of Suicide
preoccupation with death and focused on morbid thoughts
wants to give away cherished possessions
loss of interest/energy
changes in sleep
recurrent stomach aches/ headaches
reckless behavior
anti social
sudden cheerfulness after depression
Diet
Weight and fat deposition that is normal in puberty may lead to body image problems and eating disorders.
Nutritional requirements are at their peak during adolescence
Health promotion especially in adolescent girls should provide teaching about normal body changes
Vegetarian/Vegan
Benefits: Low-fat, high fiber
Reduce risk of obesity, Type 2 Diabetes, Cardiovascular disease
Economical
Disadvantages:
Vegan – low Vit. D, Vit. B12, Calcium, and omega-3 fatty acids, iron, and zinc
Vegetarian – Vit. B12
Eating Disorders
Obesity
Anorexia nervosa
Bulimia
Alcohol
Studies of 15 and 16 year olds showed cognitive impairments in teen alcohol abusers, compared with non-abusing peers, even weeks after they stop drinking.
This suggests that abuse of alcohol by teens may have long-term negative effects
Marijuana
Early, long term use linked with drop in IQ
Synthetic marijuana responsible for increased incidence of kidney failure in adolescents
Smoking Statistics
In 2013, 22.9% of high school students reported current use of a tobacco product, including 12.6% who reported current use of two or more tobacco products.
More students using smokeless tobacco or cigars
Antismoking Campaigns
Peer-led programs
Emphasize social consequences rather than long-term health problems
Use of multimedia images
School and community settings
Begin in elementary school and
continue through high school
Hospitalization and the adolescent
Major fears:
Loss of control
Altered body image
Separation from peer group
Supportive interventions for adolescents
Hospitalization of adolescents disrupts school and peer activities; they need to maintain contact with both.
Alteration in body image can be devastating
Teaching about procedures should include time without the parents present.
When parents are present, direct questions to the adolescent , not the parents
Supportive interventions for adolescents
Realize risk taking, rebelliousness,etc. is normal in adolescence
Encourage socialization with peers
Encourage increased responsibility for care and management of the disease or condition
Emphasize good appearance, stylish clothes
Encourage activities appropriate for age (driver’s license, etc.)
Developmental Care for Chronically Ill Adolescent
Privacy
Encourage to wear street clothes
Use scientific and medical terminology to prepare for procedures
Encourage questions about appearance and future with illness
Encourage peers to call and visit often
Concepts of Bodily Injury by age
Infants: After 6 months, their cognitive development allows them to remember pain.
Toddlers: They fear intrusive procedures
Preschoolers: they fear body mutilation
School-age children: They fear loss of control of their bodies
Adolescents: Their major concern is change in body image.
