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

CHAPTER 14

Two-Year Visit

Frances K. Porcher

Breathing diffi culties, 786.09

Rashes, 782.1

Fever, 780.6

Seizures, 780.39

No urine output in 12 hours, 788.2

Temper tantrums, 312.1

I. GENERAL IMPRESSION

A. Two-year old is very active, has good vocabulary, and is integral part of family.

II. NUTRITION

A. Quadruples birth weight by age 2 years.

B. Average 2-year-old weighs 12.5-13.5 kg (26-28 lbs), is 85-90 cm (34-35 in.) tall, has head circumference of 48-50 cm (19-19.5 in.).

C. Requires approximately 102 kcal/kg.

D. Needs approximately 1.2 g/kg of protein, 500-800 mg of calcium, 10 mg iron.

E. Fluoride supplement is necessary if water supply contains < 0.3 ppm fluoridation (see Appendix B).

F. Requires 2-3 servings of protein, 2-4 servings of fruit, 3-5 servings of vegetables, 6-11 servings of grains, and 2 servings of milk each day.

G. Limit juice to 4-6 oz/day. Offer skim, 1%, 2% milk versus whole milk.

H. Offer 5-6 smaller nutritious meals or snacks each day.

I. Start limiting fat intake to ≈ 30% of daily calories.

J. Child's serving is about images of a standard adult serving.

K. Needs structured mealtime environment.

L. Has unpredictable eating habits (likes one food one day but not next day).

M. Usually eats only 1-2 foods at meal.

N. Feeds self, loves finger foods.

O. Complete set of 20 primary teeth (second molars may not erupt until age 3 years).

P. Assess child's risk for hyperlipidemia.

III. ELIMINATION

A. Regular elimination pattern is usually established with soft, formed stool daily or every other day and several urinations/day.

B. Toilet training is major developmental task between ages 2½ and 3½ years.

C. Ready for toilet training if bowel movements are regular, child interested in toileting.

IV. SLEEP

A. Should be able to sleep all night and maintain one nap/day.

B. Important to have pleasant bedtime routine.

C. Not uncommon to experience nighttime sleep awakenings, bedtime difficulties.

D. May sleep in crib or small bed depending on child's size, climbing skills.

V. GROWTH AND DEVELOPMENT

A. Age of autonomy, egocentrism, negativism.

B. Gains 4.5-6.6 lbs and 2.5-3.5 in./year from ages 2-5 years.

C. Gross motor: runs without falling; kicks large ball; jumps; walks up/down stairs one step at a time.

D. Fine motor: stacks 5-6 blocks; makes/imitates horizontal/circular strokes with crayon/large pencil; manipulates/solves single-piece puzzle; can unravel, undo, untie.

E. Language: 50% of speech is understandable by stranger; has at least a 20-word vocabulary; uses 2-word phrases; understands more than says; understands and uses “I” and “you”; clearly verbalizes wants; follows 2-step commands.

F. Fears bodily harm (limit intrusive procedures, approaches).

G. Increasingly independent, loves to explore.

H. Negativity, temper tantrums often become an issue (hence, the “terrible twos”).

I. Time-out measures (no longer than 2 minutes/episode) recommended rather than hitting or spanking for discipline.

J. Consistency with discipline measures important (discipline for same behavior tomorrow as today).

K. Lots of love, reassurance needed.

VI. SOCIAL DEVELOPMENT

A. Increasingly independent, curious (exploring, climbing, hiding).

B. Active and delightful but testy and frustrating at times as child learns to become social.

C. Frustration manifested as temper tantrums.

D. Differentiates self from others but still needs frequent parental reassurance.

E. Common to experience stranger anxiety (will hide head in parent's arms/ behind legs).

F. Engages in parallel play (plays alongside peers, not with them).

G. Imitates adult activities/tasks (e.g., sweeping, dusting, shaving, combing hair).

H. Often develops fears (e.g., fear of going down toilet with flushing).

I. Needs positive behavior reinforced frequently (praise good behaviors).

VII. IMMUNIZATIONS (SEE APPENDIX A)

A. Bring up to date.

B. Consider varicella vaccine if no reliable history of disease or if not previously given.

C. Consider hepatitis A vaccine if indicated by geographical area of residence.

D. Consider tuberculin skin test (PPD) if meets risk criteria.

VIII. SAFETY

A. Install and periodically check smoke alarms.

B. Ensure crib slats are no more than 2 3/8 in. apart.

C. Avoid crib mobiles due to risk of strangulation or choking.

D. With small bed, ensure mattress is close to floor to minimize injury if child falls out of bed.

E. Encourage use of potty chair that sits directly on floor rather than toilet.

F. Remove dangling objects such as blind cords, curtain draws.

G. Supervise play and do not allow toys with small or sharp parts.

H. Supervise eating: Do not allow foods that may lead to choking (popcorn, peanuts, marshmallows, wieners, raw vegetables).

I. Use childproof lids on all medications; store medications in locked cabinet.

J. Keep household cleaning products out of reach.

K. Use gates and fences where appropriate to prevent falls.

L. Supervise in kitchen (turn pot handles away from edge of stove, store knives out of sight).

M. Supervise around water; set hot water thermostat to 120°F (48.9°C).

N. Use child-approved sunscreen with at least SPF 15.

O. Use child safety seats approved for child's weight at all times in motor vehicles. (If weighs at least 20 lbs, use forward-facing car seat in middle of backseat; never place car seat in front seat of vehicle with a passenger airbag.)

P. Teach stranger safety.

IX. ANTICIPATORY GUIDANCE

A. Nutrition.

1. Will eat variety of all food groups. Will eat larger servings.

2. Still likes finger foods, but can use child-sized fork, spoon.

3. Continues to drink skim, 1%, 2% milk (no more than 2-3 cups/day). Avoid flavored milk and soda.

4. Encourage to drink water especially if playing outside in heat.

5. Encourage to wash hands before eating.

6. Brushes teeth with fluoridated toothpaste and parents' assistance.

7. Needs dental check up.

B. Elimination.

1. Daytime and nighttime bowel movement control established by age 3 years.

2. Daytime urine control established by age 3 years. May still experience nighttime urination.

3. Needs to be encouraged to wash hands after toileting and blowing nose.

C. Sleep.

1. Continues to need regular bedtime routine.

2. Needs 10-12 hours of sleep at night (does usually awaken).

3. Usually continues to have one daytime nap.

4. Should sleep in own bed.

5. May experience nightmares.

D. Growth and development.

1. Rate of growth slowing down.

2. Gross motor: jumps in place, kicks ball, throws ball overhand, rides tricycle, climbs everything.

3. Fine motor: copies circle and cross, dresses self, feeds self using small fork, washes and dries hands, can put on T-shirt, may be able to dress self without help.

4. Language: at least 50% of speech is understandable, uses sentences, can carry on a conversation of 2-3 sentences, uses prepositions, may use adjectives, may be able to identify 4 colors, identifies friend by naming, identifies 4 pictures by naming, knows own name, age, gender.

E. Social.

1. Parallel play still prevails; unlikely to share toys.

2. Should not view more than 1 hour television/video per day.

3. Needs daily physical activities (outdoors if possible).

4. Curious about body parts, may start exploring (use correct terms for body parts).

5. Needs positive reinforcement of good behaviors.

F. Safety.

1. Needs supervision while playing, eating, when around water.

2. Continues to need child safety seat or restraint appropriate to child's weight.

3. May be able to learn own telephone number.

G. Immunizations: if current, should not need any until age 4 years.

H. When to call healthcare provider:

1. Breathing difficulties.

2. Seizures.

3. No urine output in 12 hours.

4. Rashes.

5. Fever.

6. Concerns.

I. Sibling rivalry.

1. Defined as jealousy that develops between brothers and sisters as they compete for parental time, attention, love, and approval.

2. Often occurs following arrival of second child in family.

3. Older child often becomes aggressive, acts out, or regresses.

4. Prevention is key. Discuss new baby during pregnancy, allow firstborn to help make decisions, including preparations for new baby, move older child to new bed months before arrival of new baby.

5. After baby arrives, spend one-on-one time with older child, listen to how older child feels, let child know they are special, try not to compare two siblings, and do not play favorites.

6. Passive noninterventions recommended for minor squabbles between older siblings such as ignoring the conflict or allowing children to resolve the conflict themselves.

7. Encouraging articulation of disagreements recommended for more significant conflicts in older children such as allowing siblings to express emotions and problem solve with parental support.

8. Parental intervention recommended in situations involving physical or verbal abuse–do not allow older sibling to hit new baby; avoid yelling; separate children if necessary and discuss actions after everyone has calmed down.

BIBLIOGRAPHY

Anderson, JE Sibling rivalry: When the family circle becomes a boxing ring. Contemporary Pediatrics. 2006; 23:2.

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.

Story M, Holt K, Sofka D, eds. Bright Futures in Practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health; 2002.



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