Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 12

Twelve-Month Visit

Patricia Clinton

Anemia, 280.9

No urine output in 12 hours, 788.2

Breathing diffi culties, 786.09

Rash, 782.1

Irritability, 799.2

Seizures, 780.39

I. GENERAL IMPRESSION

A. Twelve-month visit heralds onset of toddlerhood.

B. Toddler's increasing mobility opens new worlds to explore and requires close supervision to prevent injuries.

II. NUTRITION

A. Caloric needs: 98-100 kcal/kg/day.

B. Breastfeeding/formula feeding.

1. Breastfeeding may continue, but toddler is getting majority of nutrients from table food.

2. If formula feeding, discuss switching to whole cow's milk.

C. Assess for risk factors, screen for iron-deficiency anemia if necessary.

1. Birth weight 1500 grams, result of use of cow's milk or low-iron formulas during first year, low intake of iron-rich foods, low socioeconomic status.

2. Supplement as necessary (see Chapter 32 for more on iron-deficiency anemia).

D. Solids.

1. Offer infant variety of foods from all food groups.

2. Offer liquids from cup.

3. Limit juice to 4-6 oz/day. Limit whole milk to 16-24 oz/day.

E. Eating habits/safety.

1. Reinforce mealtime as family time.

2. Three meals and two snacks/day appropriate; rule of thumb for serving size is 1 tablespoon/year of age.

3. Toddler's attention span limits ability to sit for long periods.

4. Foods should be chopped into small pieces. Avoid foods that may cause choking: grapes, raisins, peanuts, popcorn, raw vegetables.

5. Encourage toddler to self-feed with spoon, cup.

6. If breastfeeding, discuss interest in weaning to cup.

7. If bottle feeding, weaning to cup should be started.

8. Reassure parents that toddlers' eating patterns are inconsistent from meal to meal; think in terms of several days when reviewing recommended servings of foods.

III. ELIMINATION

A. Voiding and stooling pattern.

1. Regular patterns may be established but these continue to be involuntary.

2. Discourage toilet training until closer to 24 months; toilet training dependent on complete myelinization of pyramidal tracts in spinal cord.

IV. SLEEP

A.Requirements.

1. 12-13 hours total/day.

2. 1-2 naps/day.

B. Environment.

1. Continue bedtime rituals; consistency is key.

2. Transitional objects continue to be important.

3. Bedtime resistance and night wakings are common.

4. Avoid naps late in day that may interfere with nighttime sleeping.

C. Safety.

1. Mattress should be in lowest position to prevent climbing out of crib.

2. No bottles in bed.

3. All cords, small objects, plastic bags, latex balloons removed.

V. GROWTH AND DEVELOPMENT

A. Physical.

1. Most toddlers will have tripled birth weight.

2. Overall growth slows; typically will gain 3-3.5 kg (6-8 lbs) in next year and gain about 12 cm (5 in.) in length.

3. Head circumference averages about 47 cm (18 in.); brain weight doubles its birth weight in first year.

B. Motor.

1. Fine.

a. Pincer grasp well developed.

b. Puts block in cup.

c. Can hold crayon/pencil and make marks on paper.

2. Gross.

a. Stands alone for a few seconds. May take some free steps.

b. Cruising around furniture.

C. Cognitive.

1. Continues in Piaget's sensorimotor stage; actions more intentional.

2. Increasing mobility fosters exploration of environment.

3. Toddler observes other's actions, listens, touches/mouths objects.

4. Play more spontaneous and self-initiated.

D. Language.

1. Uses 1-2 words.

2. “Dada” and “mama” specific.

3. Imitates sounds.

4. Begins to respond to simple commands.

5. Understands “no,” “hot.”

6. When an object is named, will look for it.

VI. SOCIAL DEVELOPMENT

A. Relationships.

1. Anxious around strangers.

2. Emotions emerge such as anger, affection.

B. Environment: conditions that foster trust and development of positive psychosocial feelings.

1. Waves “byea-bye.”

2. Plays games such as “pat-a-cake.”

3. Indicates wants.

4. Imitates activity of others.

VII. IMMUNIZATIONS (SEE APPENDIX A)

A. HepB #3 if necessary.

B. Hib #4 between 12 and 18 months.

C. IPV #3 if necessary.

D. MMR between 12 and 15 months.

E. Varicella at 12 months or after.

F. PCV 12-15 months.

G. Influenza annually.

VIII. SAFETY

A. Toddler care activities.

1. Always check bathwater temperature; make sure hot water thermostat < 120°F (48.9°C).

2. Never leave toddler alone in tub, changing table, highchair.

3. Use sunscreen, avoid prolonged sun exposure.

B. Environment.

1. Switch to toddler car seat. Never leave toddler alone in car.

2. Never leave toddler alone outside.

3. Reexamine “baby proofing” from toddler walking perspective: outlet covers, door/drawer latches, safety gates. Remove cords, wires, string, small objects, plastic bags from toddler's environment.

4. Climbing follows walking; anticipate dangers on counters, tables, stairs.

5. Keep sharp objects out of reach.

6. Maintain smoke-free environment; use smoke alarms.

7. Do not leave alone in room with pets or young children. Feed pets in area away from toddler. Do not allow infant near pet when eating. Keep litter boxes away from toddler's environment.

8. Avoid tablecloths or remove heavy or hot objects from tables with tablecloths.

9. Keep toilet lid down, remove buckets with water.

10. Protective enclosures around swimming pools, hot tubs, other water sites (ponds, fountains).

11. Provide poison control number (to be placed by telephone). Syrup of ipecac no longer recommended.

12. Keep houseplants out of reach; remove any poisonous plants.

IX. ANTICIPATORY GUIDANCE

A. Parent-toddler interaction.

1. Continue to talk, sing, tell stories to toddler.

2. Parent should make it a habit to describe what she/he is doing with toddler (e.g., “this is how we put on socks”).

3. Play games such as naming things, body parts, people.

4. Encourage reading activities with picture books, infant board books.

5. Limit TV to 1 hour or preferably less per day.

6. Toddlers explore; this includes genital area.

B. Discipline.

1. Consistency reinforces trust.

2. Discuss appropriate discipline measures aimed primarily at protecting infant from injury; cognitively, infant cannot appreciate danger or intent.

3. Positive reinforcement to support appropriate behavior; distraction continues to be effective.

4. Limit use of word “no.”

5. Spanking never appropriate.

6. Occasionally gentle physical restraint (holding toddler) may be necessary to prevent injury.

7. Decide on a few important rules and be consistent about enforcing them.

C. Oral hygiene.

1. No bottles in bed.

2. Assess for bottle mouth caries.

3. Use soft toothbrush, small pea size amount of fluoridated toothpaste. Assess fluoride source, supplement as necessary (see Appendix B).

4. Make appointment for first dental visit.

D. Illness prevention.

1. Review illness symptoms and interventions.

2. Reinforce importance of immunizations.

3. Reinforce importance of handwashing.

4. Use cool mist vaporizer for upper respiratory illness.

E. When to call healthcare provider:

1. Breathing difficulties.

2. Seizures.

3. Irritability.

4. No urine output in 12 hours.

5. Rash.6. Concerns.

BIBLIOGRAPHY

Burns CE, et al. Pediatric Primary Care: A Handbook for Nurse Practitioners. 4th ed. Philadelphia, PA: W.B. Saunders; 2009.

Centers for Disease Control and Prevention. 2011 Recommendations and Guidelines: Childhood & Adolescent Immunization Schedules.http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm. Accessed June 2, 2011.

Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior and Development. 4th ed. St. Louis, MO: Mosby; 2006.

Hagan JF, Shaw JS, Duncan P, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Porter RS, Kaplan JL. The Merck Manual Online:http://www.merck.com/mmpe/index.html. Accessed June 2, 2011.

Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems.2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

Ontario Society of Nutrition Professionals in Public Health. Pediatric Nutrition Guidelines for Primary Care Providers. Ontario, CA; 2008: http://www.osnpph.on.ca/pdfs/ImprovingOddsJune-08.pdf. Accessed June 3, 2011.

Recommendations for using fluoride to prevent and control dental caries in the United States. Morb Mortal Weekly Rep. 2001;50:RR-14.

Samour PQ, King K. Handbook of Pediatric Nutrition. 3rd ed. Sudbury, MA: Jones and Bartlett Publishers; 2005.



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