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

CHAPTER 13

Fifteen- to Eighteen-Month Visit

Susan G. Rains

Bow-legged, 736.42

Rash, 782.1

Developmental delay, 783.4

Separation anxiety, 309.21

Irritability, 799.2

Strabismus, 378.9

No urine output in 12 hours, 788.2

 

The toddler is no longer an infant. The world is forever changed by the new ability to move, explore, and control the environment.

I. NUTRITION

A. Requirements: Growth slows in toddlerhood, decreasing energy needs to 102 kcal/kg/day, 1.2 g of protein/kg/day, fluids to 115 mL/kg/day; growth may average only 4.5 lbs/year.

1. Servings should be 1-2 tablespoons of each food for each year of life, or about 1/4–1/3 of adult servings.

2. Milk (whole until age 2) should be limited to 24 oz/day (16 oz is adequate), due to lack of iron and interference with intake of other nutrients. Calcium requirements are 500 mg/day; vitamin D 200 iu/day.

3. Limit fat to 30% of diet; protein 15-20%, carbohydrates to 55%.

4. Screen for anemia if appropriate: (large amounts of cow's milk/day, especially bottle; diet deficient in other iron-rich foods).

B. Eating habits.

1. Understanding toddlers.

a. Lifelong eating habits, food preferences, and activity level have roots in the early self-feeding experiences of toddlers.

b. They are able to recognize themselves as separate from others and need to explore independence by testing limits, including feeding limits.

c. They recognize the newness and difference of foods and also crave the comfort of rituals.

d. Toddlers often have appetite slumps or are sporadic eaters. If at day-care, they may only eat well at midday with the other children, so the parent rarely sees them eat! Or they may need 2 days to get all of the food groups in!

2. Promoting good habits: Now is the time to help your child develop healthy eating habits and make good choices. As they become more independent:

a. Be a good role model. Eat meals as a family, without TV, at regularly scheduled times.

b. Provide nutritious snacks 2-3 times/day, not as a reward; limit sugar.

c. Allow choices and experimentation; do not force. Offer new foods several times in order to give the child an opportunity to learn to accept and to like it.

d. Allow toddler to self-feed with hands or utensils. Use cup, not bottle.

e. Limit fruit juice to 4-6 oz/day.

f. Serve appropriately sized portions, examples:

• 1/2 piece of fresh or V cup canned (preferably in its own juice) fruit.

• 2 tablespoons cooked vegetables.

• 1 tablespoon smooth peanut butter (thinly spread on cracker or bread).

• 1/2 egg, 2 tablespoons ground meat.

• 1/3 cup yogurt, 1/2 cup milk.

• 1-2 crackers, 1/4-1/2 slice of bread.

3. Safe eating.

a. Sit when eating; avoid eating in the car.

b. Avoid screaming, fighting, tickling while eating.

c. Avoid foods that can cause choking:

• Popcorn.

• Hot dogs, chunks of meat.

• Globs of peanut butter with or without bread.

• Large seeds, nuts, especially peanuts (or foods containing nuts).

• Hard candy, jelly beans.

• Large chunks of raw vegetables or fruits.

• Whole grapes.

• Chewing gum.

• Carrot sticks.

II. ELIMINATION: TOILET TRAINING

A. Attempting to toilet train a child younger than 24 months of age is generally unadvisable; however, most children begin to show some interest between the ages of 18-24 months.

1. Parents are encouraged to watch the child for signs of readiness:

a. Child is dry at least 2 hours at a time during the day or is dry after naps.

b. Bowel movements become regular and predictable.

c. Facial expressions, posture, or words reveal that the child is about to urinate or have a bowel movement. This is one of the most crucial signs–to be able to tell prior to the incident, not just after the event, which is an earlier skill.

d. Child asks to wear grown-up underwear.

e. Child asks to use the potty chair or toilet.

f. Child seems uncomfortable with soiled diapers and wants to be changed.

g. Child is able to follow simple directions.

h. Child is able to walk to and from the bathroom and help undress.

2. Parents are encouraged to introduce children to the “business” of toileting: allow to observe older children/parents when appropriate; obtain potty chair and allow to sit on it; allow to flush the toilet.

3. Discourage parents from considering toilet training if the child is under stress–should not suppress their desire to use the potty, but should not pressure them in any way to train, nor be surprised if they regress. Stress factors include:

a. New sibling arriving.

b. Moving houses.

c. Family crisis such as death, major illness.

4. Encourage use of proper names for body parts and for products of elimination. Without making bowel movements sound “dirty” or “nasty,” teach children that we do not play with feces.

5. Pick a potty chair that offers foot support either in the chair itself or because it is low to the floor. Read books about pottying together with the child.

6. Try to make pottying routine. Everyone generally goes first thing in the morning, before bed, before bath, after meals. Try for a few minutes, but don't fight about it as that undoubtedly will hinder the process.

7. Positive reinforcement and sensing the child's readiness and pace of learning are essential for success.

III. SLEEP

A. Requirements.

1. Averages 12 hours total/day.

2. One to two naps/day; may have difficulty combining morning and afternoon naps.

B. Difficulty with sleep.

1. Common, especially going to sleep and falling asleep.

2. May be due to separation anxiety and independence issues.

C. Strategies to assist sleep.

1. Bedtime rituals: standard sleep time, snack, quiet activity.

2. Utilizing transitional objects such as special toy, blanket.

3. Place child in bed while awake.

4. Check on child at progressively longer intervals.

5. Comfort, but do not feed, rock, place in bed with parent.

6. Ideally, institute above strategies prior to child being able to climb out of crib.

IV. GROWTH AND DEVELOPMENT

A. Physical growth slows.

1. Average increases in second year of life: 5 lbs, height 3", OFC 1".

2. Anterior fontanel closes by 18 months.

3. Head is in smaller proportion to the body.

4. Physique duck-like: lordotic, pot-bellied, bow-legged.

5. Vision binocular (true strabismus should be referred).

6. 14 teeth averaged by 18 months.

7. Immune system much better developed, but passive immunities from mother gone (especially if not breastfed) and just beginning increased exposure to antigens in environment.

B. Development.

1. Physical. Utilizing newly developed locomotion skills and wanting to control the environment. Toddlers push and carry large objects; put themselves into spaces such as boxes, cabinets, and under tables; delight in repetitive throwing and retrieving; scribbling. Handedness is established.

2. Speech. By 18 months understands much of language spoken to him, but commands very few words. Largest jump in language is in second half of second year.

3. Emotional/social. Toddlers strive for independence, i.e., autonomy, and are looking for admiration and positive reinforcement of newly found skills. Still experience dependency needs (separation anxiety) during this quest. Beginning body image development. Negativism is a part of individualization. May be becoming aware of gender.

4. Cognitive (intellectual). Toddlers are beginning to work on causality with an increase in physical abilities and memory development. Starting to see objects symbolically. Imagination begins.

Note: Early signs of autism spectrum disorder (ASD), including atypical development in socialization and communication, are now detected by pediatric providers in children as young as 18 months. Consistently, those signs include decreases in frequency of gaze to the examiner's face, social smiles, and vocalizations to others.

C. Developmental milestones.

1. By 15 months: says 3-6 words; can point to a body part; understands simple commands; walks well; stoops; climbs stairs; stacks two blocks; feeds self with fingers; drinks from a cup; listens to a story; tells what he wants by pulling, pointing, or grunting.

2. By 18 months: Walks backwards; throws ball; says 15-20 words; imitates words; uses two-word phrases; pulls a toy along the ground; stacks three blocks; uses a spoon and cup; listens to a story, looking at pictures and naming objects; shows affection; kisses; follows simple directions; points to some body parts; scribbles.

D. Developmental delay–possible referral if not present by 18 months:

1. Walks upstairs with assistance.

2. Self-feeds with spoon at times.

3. Mimics actions of others.

4. Uses at least 6 words.

V. SOCIAL

A. Growth, development, and socialization of the child are demonstrated in play activities. The toddler progresses from the sensorimotor play of infancy to parallel play, incorporating imitation, fine and gross motor skills, and new language.

B. Appropriate toys for the toddler are: swing sets, sandboxes, play kitchens, play tools, musical and “talking” toys (especially interactive ones), riding toys (especially without pedals), push toys, balls, containers, telephones, mirrors, dolls and puppets, large crayons, and books. (Contact Reach Out and Read for information in setting up a literacy promotion program in clinics and offices: http://www.reachoutandread.org.)

C. The toddler's new mobility and drive for autonomy make discipline a new challenge for the parent and caregiver. Appropriate discipline guidelines for the toddler include offering choices when available, including following a “no” with a “yes;” keep “catching the child being good;” and rewarding positive behaviors with verbal praise and physical affection. Time-out is not appropriate until 2.5-3 years.

D. Parents should be encouraged to help the child learn to express emotions such as joy, fear, anger, sadness, and frustration.

E. Dealing with temper tantrums.

1. Tantrums are a frequent occurrence in toddlers as the young child begins to establish independence and easily becomes frustrated in doing so. He also often does not have his every need met immediately (hunger and fatigue) and is even told “no” on occasion!

2. Parents should: Attend to hunger and sleep needs if possible to help allay underlying causes; stay calm, firm, and consistent; help allay frustrations by helping the child do/learn whatever it is that is frustrating them; distract the child by offering an alternate activity; quietly walk away.

3. Time out can be used with a toddler. One minute per year of age is recommended for time out. This may be too long for a toddler, however, and the adult may need to help them physically (and calmly) stay in time out, again, keeping all conversation to a minimum, to avoid reinforcing negative behavior by giving it attention. Many children quickly learn that they are able to acquire a parent's one-on-one attention with negative behavior, and often do not care if it is negative attention.

4. Do praise and give reinforcement for positive behaviors such as tantrums ceasing. Give choices if possible.

5. Spanking has no place in the discipline (which means teaching) of children. When spanking and hitting are used by parents, children often learn to use physical force to express anger and deal with conflict.

6. Signs of abnormal behaviors may include: Self-injurious behavior during a tantrum, consistent aggressive behavior toward others or destructive behavior toward objects > 50% of the time during a tantrum, high frequency of tantrums (> 5/day or > 10-20/month), tantrums > 25 minutes.

VI. SAFETY

A. Toddlers are at increased risk for injury due to increased locomotion and primitive cognition. Leading causes of death and injury and prevention strategies are listed.

B. Motor vehicles.

1. Use federally approved car seat in backseat of vehicle. May face forward if older than 1 year and > 20 lbs. Child safety seat inspection: 1-866-SEAT-CHECK; seatcheck.org.

2. Use bike helmet.

3. Teach children pedestrian/vehicle safety.

4. Never allow toddlers to play alone outside.

C. Poisoning.

1. Use childproof caps on medications; keep medications and household poisons (including plants) out of reach or better locked.

2. Have poison control number readily available for all caregivers. 1-800222-1222. Never tell children medication is candy.

3. Screen for lead risk.

D. Burns.

1. Use caution in kitchen with young children present.

2. Turn handles of cooking utensils away from outer edge of stove.

3. Adjust hot water to 120°F.

4. Keep matches/candles out of reach.

5. Use sunscreen when children are exposed to sunlight.

6. Keep sockets covered and cords out of sight.

7. Have working smoke detector on every floor of the house.

E. Drowning.

1. Supervise closely near any water, including buckets.

2. Fence swimming pools.

3. Close bathroom doors and put lid down on toilet.

4. Utilize life preservers in addition to above.

F. Choking and suffocation.

1. Do not give danger foods listed in nutrition section (including nuts, hot dogs, gum, hard candy).

2. Only allow play with age-appropriate items (no small pieces).

3. Discard old appliances/furniture or remove doors.

4. Keep automatic garage door opener inaccessible.

5. Select safe toy chests without heavy, hinged lid.

G. Falls.

1. Confine play in fenced areas.

2. Supervise all climbing play.

3. Place gates at top and bottom of stairs.

4. Lock windows, screens, doors.

5. Keep crib rails up and mattress at lowest level.

6. Keep bumper pads and large stuffed animals out of crib or playpen (child may climb on top).

7. Dress in safe clothing that will not catch or drag.

H. Other injuries.

1. Never leave children alone in a car or at home.

2. Do not allow play near any machinery.

3. Do not allow running with sharp objects, or with anything in the mouth.

4. Teach children to avoid strange animals, especially ones that are eating.

5. Avoid personalized clothing in a public place.

6. Use safety glass and decals on large windows/doors.

7. Remove guns from house.

VII. IMMUNIZATIONS

A. HIB #4 (if not previously given).

B. PCV #4.

C. IPV #3.

D. DTaP #4.

E. HepB #3 (if not previously given).

F. MMR #1 (if not previously given; may see moved to 15 months to increase immunogenicity).

G. Varivax (if not previously given; may see moved to 15 months to increase immunogenicity).

H. Influenza seasonally.

VIII. OTHER SCREENINGS IF RISK ASSESSMENT INDICATES

A. Dental (ensure fluoride source).

B. B/P: if high risk history.

C. Vision: prematurity 32 weeks, family history of ophthalmologic problems (other than acuity).

D. Hearing: caregiver concern, postnatal infection, head trauma, family history, certain syndromes associated with hearing loss.

E. TB: exposure, born outside United States, HIV associated.

IX. ANTICIPATORY GUIDANCE

A. Primary responsibility of the PNP is to assist the parent in understanding and parenting this emerging person–the toddler–and his thoughts, behaviors, and needs, as well as attending to the parent's needs.

B. Social competence.

1. Give individual attention, create opportunities for exploration and physical action.

2. Encourage self-care, self-expression, choices.

3. Limit number of rules, but consistently enforce them.

4. Suggest acceptable alternatives.

5. Keep discipline brief.

6. Allow assertiveness within limits, but no hitting, biting, or aggressive behavior.

7. Reassure once negative behavior has stopped.

8. Delay toilet training.

9. Expect genital curiosity.

C. Family relationships.

1. Parent needs to take time for himself or herself and with partner.

2. Pick up toddler, hold, cuddle, show affection.

3. Listen, show respect and interest in activities.

4. Encourage all family members to spend time playing with toddler.

5. Help child express emotions.

6. Keep family outings short.

7. Do not expect child to share all toys.

8. Help siblings resolve conflicts. Allow older children own space/things.

9. Serve as role model for healthy habits and care.

D. Health promotion.

1. Nutrition.

a. Eat meals as family.

b. Allow toddler to self-feed with hands and utensils and drink from cup, not bottle.

c. Provide healthy choices, allow experimentation, and do not force eating.

d. Give two to three snacks/day, not as a reward; limit sugar.

e. Avoid choking foods.

2. Oral health.

a. Never put to bed with a bottle.

b. Brush teeth (allow imitation, but parent must do the job well).

c. Investigate level of fluoride in child's water.

d. Encourage making appointment with dentist.

3. Injury prevention (expanded list in safety section).

a. Maintain smoke-free environment.

b. Check smoke and carbon monoxide detectors.

c. Check car seat use.

d. Reexamine home to ensure it is childproof.

e. Supervise toddler closely, especially near dogs, lawnmowers, streets, and driveways.

f. Ensure water safety.

g. Use sunscreen.

h. Discuss first-aid procedures.

E. Community interaction.

1. Assess needs of the family for appropriate referrals: financial assistance, Medicaid, housing, transportation.

2. Refer child for appropriate developmental, physical, behavioral problems.

3. Refer parent to support group if appropriate.

4. Review childcare.

5. Maintain community involvement by attending local activities.

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