Health Promotion of the Toddler and Family

Proportional Changes

Growth slows considerably during toddlerhood. The average weight at 2 years is 12 kg (26.5 lb). The average weight gain is 1.8 to 2.7 kg (4 to 6 lb) per year. By years of age, toddlers have quadrupled their birth weight. The rate of increase in height also slows. The usual increment is an addition of 7.5 cm (3 inches) per year and occurs mainly in elongation of the legs rather than the trunk. The average height of a 2-year-old is 86.6 cm (34 inches). In general, adult height is about twice the child’s height at 2 years of age. Accurate measurement of height and weight during the toddler years should reveal a steady growth curve that is steplike rather than linear (straight), which is characteristic of the growth spurts during the early childhood years.

The rate of increase in head circumference slows somewhat by the end of infancy, and head circumference is usually equal to chest circumference by 1 to 2 years of age. The usual total increase in head circumference during the second year is 2.5 cm (1 inch). Then the rate of increase slows until age 5 years, when the increase is less than 1.25 cm (0.5 inch) per year. The anterior fontanel closes between 12 and 18 months of age.

Chest circumference continues to increase and exceeds head circumference during the toddler years. Its shape also changes as the transverse (or lateral) diameter exceeds the anteroposterior diameter. After the second year the chest circumference exceeds the abdominal measurement, which, in addition to the growth of the lower extremities, gives the child a taller, leaner appearance. However, the toddler retains a squat, “pot-bellied” appearance because of the less well-developed abdominal musculature and short legs (Fig. 14-1). The legs retain a slightly bowed or curved appearance during the second year from the weight of the relatively large trunk.

Sensory Changes

Visual acuity of 20/40 is considered acceptable during the toddler years. Full binocular vision is well developed, and any evidence of persistent strabismus should receive professional attention as early as possible to prevent amblyopia. Depth perception continues to develop, but because of the child’s lack of motor coordination, falls from heights remain a persistent danger.

The senses of hearing, smell, taste, and touch become increasingly well developed, coordinated with each other, and associated with other experiences. Toddlers use all the senses to explore the environment. Toddlers visually inspect an object by turning it over; they may taste it, smell it, and touch it several times before they are satisfied with their investigation. They will shake it to see if it makes noise and vigorously test its durability.

Another example of the integrated function of the senses is the toddler’s development of specific taste and texture preferences. The child is much less likely than infants to try a new food because of its appearance or smell, not just its taste. Likewise a toddler is likely to reject a new food because of its texture. Nonsensory associations with objects also take on significance. For example, if parents refuse a particular food because of their dislike, they will transfer this negative connotation to the child before the child has had an opportunity to taste it. Awareness of these factors is important in several areas of childrearing, such as feeding, teaching socially acceptable habits, and reinforcing appropriate behavioral responses to various situations.

Touch continues to be important to the toddler. Descending development of the spinal tract is evidenced by increased sensation in the lower extremities, such as ticklish feet. Pleasant tactile sensations soothe and comfort the toddler, especially in times of stress or fatigue.

Maturation of Systems

Most of the physiologic systems are relatively mature by the end of toddlerhood. By the end of the first year, all the brain cells are present but continue to increase in size. Myelination of the spinal cord is almost complete by 2 years of age, which parallels the completion of most of the gross motor skills associated with locomotion. Brain growth is 75% completed by the end of 2 years.

Development of various areas of the brain seems to correspond with the child’s progressive intellectual capacity. As development progresses, specific changes take place in various areas of the cerebral cortex, such as the Broca area for speech and cortical areas for control of the legs, hands, feet, and sphincters. Because this neuromotor organization is so inclusive, complex, and intricate, the child is limited in the ability to attend to any one aspect of behavior for more than a few minutes.

Between 2 and 3 years of age, coordination and consolidation of these voluntary functions allow the toddler to listen better, look longer, and have an extended attention span. Although postural control is increasingly developed as myelination of the spinal cord advances, the immaturity of this control, combined with the child’s limited experiences and lack of visual perception, makes it difficult to do simple acts such as seating oneself in a chair or climbing down stairs.

Volume of the respiratory tract and growth of associated structures continue to increase during early childhood, lessening some of the factors that predisposed the child to frequent and serious infections during infancy. However, the internal structures of the ear and throat continue to be short and straight, and the lymphoid tissue of the tonsils and adenoids continues to be large. As a result, otitis media, tonsillitis, and upper respiratory tract infections are common. The respiratory and heart rates slow, and the blood pressure increases (see inside back cover). Respirations continue to be abdominal.

The digestive processes are fairly complete by the beginning of toddlerhood. The acidity of the gastric contents continues to increase and has a protective function because it destroys many types of bacteria. Stomach capacity increases to allow for the usual schedule of three small meals a day.

One of the more prominent changes of the gastrointestinal system is the voluntary control of elimination. With complete myelination of the spinal cord, the toddler gradually achieves control of anal and urethral sphincters. The physiologic ability to control the sphincters occurs somewhere between ages 18 and 24 months. Bladder capacity also increases considerably. By 14 to 18 months of age the child is able to retain urine for up to 2 hours or longer.

The skin functionally matures during early childhood. The epidermis and dermis are more tightly bound together, increasing their resistance to infection and irritation and creating a more effective barrier against fluid loss. Production of sebum is minimal, which contributes to the development of dry skin. The eccrine glands are functional during early childhood and react to changes in temperature, but they produce minimum amounts of sweat. Hair grows thicker and coarser and usually darkens and loses some curliness. Fine hair is evident on the lower arms and legs. Production of adipose tissue declines as hyperplasia of muscle cells increases. With the concurrent growth of the lower extremities, the child assumes more adultlike proportions.

Under conditions of moderate variation in temperature, the toddler rarely has the difficulties of the young infant in maintaining body temperature. The capillaries are able to conserve core body temperature by constricting in response to cold and dilating in response to heat. Shivering, an involuntary act that results in rhythmic muscle contraction, which increases cellular metabolism and produces heat, is much more effective as a source of thermogenesis. The child also learns mechanisms to control body temperature—putting on clothing when cold or removing it when warm.

The defense mechanisms of the tissues and blood, particularly phagocytosis, are much more efficient in the toddler than in the infant. The production of antibodies is well established. Immunoglobulin G, which neutralizes microbial toxins, reaches adult levels by the end of the second year of life. Passive immunity from maternal transfer during fetal life disappears by the beginning of toddlerhood. Immunoglobulin M, which responds to artificial immunizing techniques and combats serious infection, attains adult levels during late infancy. Immunoglobulins A, D, and E increase gradually, not reaching eventual adult levels until later childhood. Many young children demonstrate a sudden increase in colds and minor infections when entering daycare or preschool because of exposure to new antigens.

Gross and Fine Motor Development

The major gross motor skill during the toddler years is the development of locomotion. By 12 to 13 months of age toddlers walk alone, using a wide stance for extra balance; by age 18 months they try to run but fall easily. Between 2 and 3 years of age, refinement of the upright, biped position is evident in improved coordination and equilibrium. By age 2 years toddlers can walk up and down stairs, and by age years they jump using both feet, stand on one foot for a second or two, and manage a few steps on tiptoe. By the end of the second year they stand on one foot, walk on tiptoe, and climb stairs with alternate footing.

Fine motor development is demonstrated in increasingly skillful manual dexterity. Once toddlers achieve pincer grasp, usually at 9 to 10 months of age, they combine this skill with other developing sensory and cognitive abilities. For example, by age 12 months they are able to grasp a very small object. By age 15 months they can drop a pellet into a narrow-necked bottle. Casting or throwing objects and retrieving them become an almost obsessive activity at about 15 months. By 18 months of age they can throw a ball overhand without losing their balance.

Visual perception of geometric shapes is also evident at this time. At age 12 months children selectively look at a round hole in a special form board but are unable to insert a round object. By age 15 months they promptly place the round object in the hole, even if the board is revised or turned upside down. Spatial relations also are evident in their ability to build a tower with blocks: by age 18 months, a tower of three or four blocks; by age 24 months, a tower of six or seven blocks; and by age 30 months, a tower of eight blocks or more.

Fine motor skill and visual ability are demonstrated in toddlers’ progressive adeptness in manipulating a pencil or crayon. By age 15 months they scribble spontaneously, and by age 24 months they imitate a circular stroke and a vertical line. By the end of the toddler period, the child can copy a circle and imitate a cross.

Mastery of gross and fine motor skills is evident in all phases of the child’s activity, such as play, dressing, language comprehension, response to discipline, social interaction, and propensity for injuries. Activities occur less in isolation and more in conjunction with other physical and mental abilities to produce a purposeful result. For example, the toddler walks to reach a new location, releases a toy and picks it up again or chooses a new one, and scribbles to look at the image produced. The possibilities of the exploration, investigation, and manipulation mastery of the environment—and its hazards—are endless.

• Differentiation of self from others, particularly the mother or primary caregiver

• Toleration of separation from parents

• Ability to withstand delayed gratification

• Control over bodily functions

• Acquisition of socially acceptable behavior

• Verbal means of communication

• Ability to interact with others in a less egocentric manner

Developing a Sense of Autonomy (Erikson)

According to Erikson (1963), the developmental task of toddlerhood is acquiring a sense of autonomy while overcoming a sense of doubt and shame. As infants gain trust in the predictability and reliability of their parents, environment, and interaction with others, they begin to discover that their behavior is their own and that it has a predictable, reliable effect on others. However, although they are aware of their will and control over others, they are confronted with the conflict of exerting autonomy and relinquishing the much enjoyed dependence on others. Exerting their will has definite negative consequences, whereas retaining dependent, submissive behavior is generally rewarded with affection and approval. On the other hand, continued dependency creates a sense of doubt regarding their potential capacity to control their actions. This doubt is compounded by a sense of shame for feeling this urge to revolt against others’ will and a fear that they will exceed their own capacity for manipulating the environment. The latter fear is a basis for instituting limit setting and consistent discipline at this age. Without appropriate limits on what is acceptable versus unacceptable behavior, children have no guidelines for establishing the end points of their ability to control.

Just as the infant has the social modalities of grasping and biting, the toddler has the newly gained modality of holding on and letting go. Holding on and letting go are evident in how the toddler uses the hands, mouth, eyes, and, eventually, sphincters when toilet training is begun. Children constantly express these social modalities in play activities such as casting or throwing objects; taking objects out of boxes, drawers, or cabinets; holding on tighter when someone says, “No, don’t touch”; and spitting out food as taste preferences become strong.

Several characteristics, especially negativism and ritualism, are typical of toddlers in their quest for autonomy. As toddlers attempt to express their will, they often act with negativism, giving a negative response to requests. The words “no” or “me do” can be the sole vocabulary. Toddlers express emotions strongly, usually in rapid mood swings. One minute toddlers can be engrossed in an activity, and the next minute they might be violently angry because they were unable to manipulate a toy or open a door. If scolded for doing something wrong, they can have a temper tantrum and almost instantaneously pull at the parent’s legs to be picked up and comforted. Understanding and coping with these swift changes is often difficult for parents. Many parents find the negativism exasperating and, instead of dealing constructively with it, give in to it, which further threatens the child’s search for acceptable methods of interacting with others (see p. 568).

In contrast to negativism, which frequently disrupts the environment, ritualism, the need to maintain sameness and reliability, provides a sense of comfort. Toddlers can venture out with security when they know that familiar people, places, and routines still exist. One can easily understand why change, such as hospitalization, represents such a threat to these children. Without the comfortable rituals, they have little opportunity to exert autonomy. Consequently, dependency and regression occur (see p. 569).

Erikson focuses on the development of the ego, which may be thought of as reason or common sense, during this phase of psychosocial development. The child struggles to deal with the impulses of the id, tolerate frustration, and learn socially acceptable ways of interacting with the environment. The ego becomes evident as the child is able to delay gratification.

This stage also sees a rudimentary beginning of the superego, or conscience, which is the incorporation of the morals of society and the process of acculturation. With the development of the ego, children further differentiate themselves from others and expand their sense of trust in self. But as they begin to develop awareness of their own will and capacity to achieve, they also become aware of their ability to fail. This ever-present awareness of potential failure creates doubt and shame. Successful mastery of the task of autonomy necessitates opportunities for self-mastery while withstanding the frustration of necessary limit setting and delayed gratification. Opportunities for self-mastery are present in appropriate play activities, toilet training, the crisis of sibling rivalry, and successful interactions with significant others.

Sensorimotor Phase (Piaget)

The period from 12 to 24 months of age is a continuation of the final two stages of the sensorimotor phase (Table 14-1). During this time the cognitive processes develop rapidly and at times seem similar to mature thinking. However, reasoning skills are still primitive and need to be understood to effectively deal with the typical behaviors of this age child. The main cognitive achievement of early childhood is the acquisition of language, which represents mental symbolism.

In the fifth stage, tertiary circular reactions (from 13 to 18 months of age), the child uses active experimentation to achieve previously unattainable goals. Newly acquired physical skills are increasingly important for the function they serve rather than for the acts themselves. The child incorporates the old learning of secondary circular reactions and applies the combined knowledge to new situations, with emphasis on the results of the experimentation. In this way there is the beginning of rational judgment and intellectual reasoning. During this stage the child further differentiates self from objects. This is evident in the child’s increasing ability to venture away from the parent and to tolerate longer periods of separation.

Awareness of a causal relationship between two events is apparent. After flipping a light switch, toddlers are aware that a response occurs. However, they are not able to transfer that knowledge to new situations. Therefore every time they see what appears to be a light switch, they must reinvestigate its function. Such behavior demonstrates the beginning of categorizing data into distinct classes, subclasses, and so on. Innumerable examples of this type of behavior occur as toddlers repeatedly explore the same object each time it appears in a new place. A classic example is their curiosity about electrical outlets. Even if they receive a shock from one of them, they will adamantly poke and inspect every other outlet. This inability to transfer information leaves toddlers particularly vulnerable to injuries. However, traces of memory are evident because they usually avoid the outlet where the shock occurred.

Because classification of objects is still basic, the appearance of an object indicates its function. For example, if the child’s toys are stored in a paper bag or large container, the toddler does not perceive a difference between that toy receptacle and the garbage pail or laundry basket. If allowed to turn over the toy receptacle, the child will just as quickly do the same to other similar objects because, in the child’s mind, there is no difference. Expecting toddlers to judge which receptacles are permissible to explore and which are not is inappropriate for this age-group. Instead, the forbidden object, such as the garbage pail, should be placed out of reach. This has significant implications for prevention of accidents and accidental ingestion of injurious agents.

The discovery of objects as objects leads to an awareness of their spatial relationships. Children are able to recognize different shapes and their relationship to each other. For example, they can fit slightly smaller boxes into each other (nesting) and can place a round object into a hole, even if the board is turned around, upside down, or reversed. However, they cannot do the same thing with a square until 2 years of age. Children are also aware of space and the relationship of their body to dimensions such as height. They will stretch, stand on a low stair or stool, and pull a string to reach an object.

Object permanence has also advanced. Although they still cannot find an object that has been displaced and is no longer visible or has been moved from under one pillow to another without their seeing the change, toddlers are increasingly aware of the existence of objects behind closed doors, in drawers, and under tables. Parents are usually acutely aware of this developmental achievement because they find high places and locked cabinets to be the only areas inaccessible to toddlers. Parents also experience toddlers’ protest behaviors when the parents leave because toddlers are aware that their parents are absent when they cannot see them.

During ages 19 to 24 months the child is in the final sensorimotor stage, invention of new means through mental combinations. This stage completes the more primitive, autistic thought processes of infancy and prepares the way for more complex mental operations during the phase of preoperational thought. One of the most dramatic achievements of this stage is in the area of object permanence. Children will now actively search for an object in several potential hiding places. In addition, they can infer a cause when only experiencing the effect. They can infer that an object was hidden in any number of places even if they only saw the original hiding place.

Imitation displays deeper meaning and understanding. Earlier, imitation was concrete and action oriented. For example, “bye-bye” was a behavioral response more than a conceptual gesture of departure. Now it has a broader meaning, such as Daddy is going to work, it is time for a walk, or something is no longer present. There is greater symbolization to imitation.

One type of symbolic imitation is domestic mimicry, the imitation of household activity. Toddlers are acutely aware of others’ actions and attempt to copy them in gestures and in words. They can imitate the parents’ performance of a household task both physically and verbally (Fig. 14-2). Parents often remark how accurately they see themselves when the child engages in domestic mimicry. Such activity is part of the child’s learning sex-role behavior. Identification with the parent of the same sex becomes apparent by the second year and represents the child’s intellectual ability to differentiate models of behavior and to imitate them appropriately.

The concept of time is still embryonic, but children have some sense of timing in terms of anticipation, memory, and the limited ability to wait. They may listen to the command, “Just a minute,” and behave appropriately. However, their sense of timing is exaggerated—1 minute can last an hour. Toddlers’ limited attention spans also indicate their sense of immediacy and concern for the present.

Egocentrism, or the inability to envision situations from perspectives other than one’s own, is evident in all aspects of toddlers’ behavior. They see, experience, and live every event in reference to themselves. A common example of egocentric behavior is the toddler who takes a toy away from another child. The toddler is concerned only with playing with the toy and is unable to conceptualize that taking the toy away will make the other child unhappy.

Preoperational Phase (Piaget)

At approximately 2 years of age the child enters the preconceptual phase of cognitive development, which lasts until about age 4 years. The preconceptual phase is a subdivision of the preoperational phase, which spans ages 2 to 7 years. The preconceptual phase is primarily one of transition that bridges the purely self-satisfying behavior of infancy and the undeveloped socialized behavior of latency. The principal characteristics of this stage are egocentric use of language and dependence on perception in problem solving.

From ages 2 to 4 years children learn a variety of words and increasingly use language. In fact, toddlers talk a lot. Speech is primarily of two types: egocentric or socialized. Egocentric speech consists of repeating words and sounds for the pleasure of hearing oneself and is not intended to communicate. This collective monologue reflects the child’s lingering self-centeredness.

Socialized speech is for communication; however, it is still egocentric in that children communicate about themselves to others. Before age 3 most speech is directed at self-fulfillment or self-reference, such as, “Want drink,” or “I do,” and is directed mostly toward adults. Because children think that everyone else’s world is the same as theirs, they expect others to understand their verbal messages even when limited information is conveyed.

Preoperational thinking implies that children cannot think in terms of operations—the ability to manipulate objects in relation to each other in a logical fashion. Rather, toddlers think primarily based on their perception of an event. Problem solving is based on what they see or hear directly rather than on what they recall about objects and events (Box 14-1).

Within the second year the child increasingly uses language symbolically and is concerned with the “why” and “how” of things. For example, a pencil is “something to write with” and food is “something to eat.” However, such mental symbolization is closely associated with prelogical reasoning. For instance, a needle is “something that hurts.” Such painful experiences take on new significance because memory is associated with the specific event and fears are likely to develop, such as resistance to people who wear uniform scrubs or rooms that look like the practitioner’s office. Sometimes parents and health care personnel underestimate the child’s ability to recall events and give little thought to preparation for visits to a practitioner’s office or other health facility, resulting in fears that can last a lifetime. Because of the vulnerability of these early years, it is essential to prepare children for new experiences, whether it is a new baby-sitter, a primary practitioner, or a visit to the dentist.

Separation and Individuation

A major task of the toddler period is differentiation of self from significant others, usually the mother. The differentiation process consists of two phases: separation, the children’s emergence from a symbiotic fusion with the mother; and individuation, those achievements that mark children’s assumption of their individual characteristics in the environment. Although the process begins during the latter half of infancy, the major achievements occur during the toddler years.

Toddlers have an increased understanding and awareness of object permanence and some ability to withstand delayed gratification and tolerate moderate frustration. They begin to lose some of their resistance to separation yet appear even more concerned about the parent’s whereabouts. They have learned from experience that parents exist when physically absent. Repetition of events such as going to bed without the parents but waking to find them again reinforces the reliability of such brief separations. Consequently, toddlers are able to venture away from their parents for brief periods because of the security of knowing that the parents will be there when they return. Verbal and visual reassurance from the parent gradually replaces some of the previous need to be physically close for comfort.

Toddlers also show less fear of strangers, but only when their parents are present. When left alone with a stranger, they are fearful and acutely anxious; manifest depressive behavior, such as crying and withdrawal; and may become restless, hyperactive, or passive, reverting to regressive behaviors. Such reactions may be evident when a child is left with a baby-sitter; is beginning kindergarten, preschool, or daycare; or is hospitalized. (See Chapter 26.)

These behaviors are not pathologic or harmful if parents realize how desperately their children need them. Indiscriminate friendliness toward strangers and lack of anxiety during separation from parents may be reasons for concern. Sensitive, perceptive parents will be aware of the child’s need for increased love, affection, and attention when they are together. An attitude such as “They will get used to the baby-sitter” will not help young children positively tolerate separation.

According to Harpaz-Rotem and Bergman (2006), the separation-individuation phase encompasses the phenomenon of rapprochement; as the toddler separates from the mother and begins to make sense of experiences in the environment, the child is drawn back to the mother for assistance in verbally articulating the meaning of the experiences. Developmentally the term rapprochement means the child moves away and returns for reassurance. If the mother’s response to the toddler is inappropriate, the toddler may experience insecurity and confusion.

Parents often need help in realizing the necessity of preparing children for an inevitable separation. Particularly with the firstborn, parents tend to overprotect children, shield them from any anxiety-producing experience, and insulate them from less than immediate gratification. Although this is not necessarily harmful, especially if opportunities for independence are allowed later, it does not prepare children for unexpected events. A typical example is the birth of a sibling. The child is faced with the crisis of sibling rivalry and separation from the parent. Allowing children to experience brief periods of separation during early infancy prepares them for such experiences later. Indeed, they may still manifest the typical behaviors of protest, but they will also have learned that their mother or father always returns. Therefore it is easy to appreciate the tremendous loss that the death of a parent represents for young children; unlike their other experiences with separation, this time the parent will not return.

Transitional objects, such as a favorite blanket or toy, provide security for young children, especially when they are separated from parents, are dealing with a new stress, or are just fatigued (Fig. 14-3). Security objects often become so important to toddlers that they refuse to let them be taken away. Such behavior is normal; there is no need to discourage this tendency. During separations, such as daycare, hospitalization, or even overnight stays with a relative, transitional objects should be provided to minimize any feelings of fear or loneliness.

Learning to tolerate and master brief periods of separation are important developmental tasks of children in this age-group. In addition, it is a necessary component of parenting because brief periods of separation from their children allow parents to recoup their energy and patience and to avoid directing their irritations and frustrations at the children.

Language Development

The most striking characteristic of language development during early childhood is the increasing level of comprehension. Although the number of words acquired—from about 4 at 1 year of age to approximately 300 at age 2 years—is notable, the ability to understand speech is much greater than the number of words the child can say. Bilingual children can also achieve their early linguistic milestones in each language at the same time and produce a substantial number of semantically corresponding words in each of their two languages from the first words or signs (Petitto, Katerlos, Levy, et al, 2001).

At age 1 year the child uses one-word sentences, or holophrases. The word “up” can mean “pick me up” or “look up there.” For the child the one word conveys the meaning of a sentence, but to others it may mean many things or nothing. At this age about 25% of the vocalizations are intelligible. By the age of 2 years the child uses multiword sentences by stringing together two or three words, such as the phrases, “mama go bye-bye” or “all gone,” and approximately 65% of the speech is understandable. At 30 months the toddler knows her or his full name. By 3 years the child puts words together into simple sentences, begins to master grammatical rules, acquires five or six new words daily, knows his or her age and gender, and can count three objects correctly (Feigelman, 2007). Looking at books during this period provides an ideal setting for further language development (Feigelman, 2007). Authorities have evaluated the impact of television viewing on toddler language development and found that those who started watching television at less than 12 months and who watched longer than 2 hours per day had significant language delays (Chonchaiva and Pruksananonda, 2008). Adult-child conversations with infants and toddlers have been shown to positively affect language development; the researchers recommend reading, storytelling, and interactive adult-child communication (Zimmerman, Gilkerson, Richards, et al, 2009).

Gestures (such as putting phone to ear or pointing) precede or accompany each of the language milestones up to 30 months of age. Once language is sufficiently mastered, gestures phase out and the pace of word learning increases (Bates and Dick, 2002).

Personal-Social Behavior

One of the most dramatic aspects of development in the toddler is personal-social interaction. Parents frequently wonder why their manageable, docile, lovable infant has turned into a determined, strong-willed, volatile-tempered little “tyrant.” In addition, the tyrant can swiftly and unpredictably revert back to the adorable infant. All this is part of growing up and is evident in such areas as dressing, feeding, playing, and establishing self-control.

Toddlers are developing skills of independence, which are evident in all areas of behavior. By age 15 months children feed themselves, drink well from a covered cup, and manage a spoon, with considerable spilling. By age 24 months they use a spoon well, and by age 36 months they may be using a fork. Between ages 2 and 3 years they eat with the family and like to help with chores such as setting the table or removing dishes from the dishwasher, but they lack table manners and may find it difficult to sit through the family’s entire meal (see Table 14-3).

In dressing, toddlers also demonstrate strides in independence. The 15-month-old child helps by putting the arm or foot out for dressing and pulls shoes and socks off. The 18-month-old child removes gloves, helps with pullover shirts, and may be able to unzip. By age 2 years the toddler removes most articles of clothing and puts on socks, shoes, and pants without regard for right or left and back or front. Toddlers still need help to fasten clothes.

Toddlers also begin to develop concern for the feelings of others and develop an understanding of how adult expectations for behavior apply to specific situations (e.g., causing a sibling to cry while playing rough). As their understanding increases, they develop control. Age-appropriate discipline contributes to healthy social and emotional development. Positive reinforcement, redirection, and time-out are appropriate for most toddlers. It is recognized that social and emotional problems can develop in the youngest children. Early screening and intervention promote more positive outcomes as the young child grows and develops.

Play

Play magnifies toddlers’ physical and psychosocial development. Interaction with people becomes increasingly important. The solitary play of infancy progresses to parallel play—the toddler plays alongside, not with, other children. Although sensorimotor play is still prominent, there is much less emphasis on the exclusive use of one sensory modality. The toddler inspects the toy, talks to the toy, tests its strength and durability, and invents several uses for it.

Play assumes many forms and serves several functions. Toddlers benefit from a wide variety of play interactions (alone, with other children, with adults), environments (own home, other children’s homes, park), and activities (active, quiet, organized, unstructured).

Imitation is one of the most distinguishing characteristics of play and enriches children’s opportunity to engage in fantasy. With less emphasis on sex-stereotyped toys, play objects such as dolls, carriages, dollhouses, dishes, cooking utensils, child-sized furniture, trucks, and dress-up clothes are used by both sexes; however, boys may be more interested than girls in activities related to trucks, trailers, cars, miniature plastic soldiers or superheroes, and building blocks, whereas girls may prefer doll-related activities (Fig. 14-4).

Increased locomotive skills make push-pull toys; stick horses; straddle trucks or cycles; a small, low gym and slide; variously sized balls; and rocking horses appropriate for the energetic toddler. Finger paints, thick crayons, chalk, chalkboard, paper, and puzzles with large, simple pieces use the child’s developing fine motor skills. Interlocking blocks in varied sizes (but large enough to avoid aspiration) and shapes provide hours of fun and, during later years, are useful objects for creative and imaginative play. The most educational toy is the one that fosters the interaction of an adult with a child in supportive, unconditional play. Parents and other providers are encouraged to allow children to play with a variety of simple toys that foster creative thinking (such as blocks, dolls, and clay), rather than passive toys that the child observes (battery-operated or mechanical). Active play time should also be encouraged over the use of computer or video games, which are more passive (Ginsburg and American Academy of Pediatrics, 2007). Toys are never substitutes for the attention of devoted caregivers, but toys can enhance these interactions (Glassy, Romano, and Committee on Early Childhood, Adoption, and Dependent Care, 2003).

Certain aspects of play are related to emerging linguistic abilities. Talking is a form of play for toddlers who enjoy musical toys such as age-appropriate cassette players, talking dolls and animals, and toy telephones. Appropriate children’s television programs are excellent for children in this age-group, who learn to associate words with visual images. However, parents should limit total media time to 1 to 2 hours of high-quality programming per day (American Academy of Pediatrics, 2001). Toddlers also enjoy “reading” stories from a picture book and imitating the sounds of animals.

Tactile play is also important for the exploring toddler. Water toys, a sandbox with pail and shovel, finger paints, soap bubbles, and clay provide excellent opportunities for creative and manipulative recreation. Adults sometimes forget the fascination of feeling slippery textures such as mud, catching airy bubbles, squeezing and reshaping clay, or smearing paints. These types of unstructured activities are as important as educational play to allow children freedom of expression.

Selecting Toys

The type of toys chosen by and provided for children can facilitate learning and development in the areas just described. Toys that are small replicas of the culture and its tools help children assimilate their culture and learn gender and occupational roles. Toys that require pushing, pulling, rolling, and manipulating teach children about the physical properties of the items and help develop muscles and coordination. Such toys also allow toddlers to use newly developed fine and gross motor skills; children can push, pull and bang away on such objects and release frustration rather than acting out with inappropriate behavior. Toddlers can learn rules and the basic elements of cooperation and organization through board games.

Because they can be employed in a variety of ways, raw materials or multidimensional toys are best for enhancing skills and stimulating the imagination. Through manipulation, playthings such as boxes, clay, and blocks can assume a multitude of symbolic forms and inspire creative impulses. For example, building blocks can be used to construct a variety of structures, to count, and to learn shapes and sizes. “Educational” toys such as puzzles are less flexible. Families can encourage children’s toy play in a number of ways.

Play materials do not need to be expensive or elaborate. Infants and small children get enjoyment from simple kitchen utensils such as wooden spoons and small plastic plates to bang, pot lids to clang together, and a nest of measuring spoons to rattle. Empty cartons, especially oversized ones used to ship furniture, can assume the function of clubrooms, hideaways, and other private places. For older toddlers, a mound of dirt can become a place for rolling toy cars and balls and digging holes during summer and a place for sliding in winter. Paper is a fascinating and versatile raw material for children of any age, and most books on toy materials include recipes for play dough and finger paint.

Toy Safety

The selection of toys and play equipment is a joint effort between parents and children, but evaluating their safety is the adult’s responsibility. Government agencies do not inspect and police all toys on the market. Therefore adults who purchase play equipment, supervise purchases, or allow children to use play equipment need to evaluate its safety, including toys that are gifts or those that are purchased by the children themselves. Adults should also be alert to notices of defective toys and manufacturer recalls. Parents and health care workers can obtain information on a variety of recalled products and can report potentially dangerous toys and child products to the U.S. Consumer Product Safety Commission* or, in Canada, the Canadian Toy Testing Council.† Printable tips on toy safety are also available from Safe Kids Worldwide (www.safekids.org).

• Offering the child options instead of an “all or none” position

• Picking one’s battles carefully and ignoring small skirmishes over unimportant issues

• Giving comfort once the child is able to control emotions but not giving in to the original request

• Praising the child for positive behavior when he or she is not having a tantrum

Nutritional Counseling

Eating habits established in the first 2 to 3 years of life tend to have lasting effects on subsequent years. If food is used as a sign of approval, a child may overeat for nonnutritive reasons. If parents force food and mealtime is consistently unpleasant, the usual pleasure associated with eating may not develop. Mealtimes should be enjoyable rather than times for discipline or family arguments. The social aspect of mealtime may be distracting for young children; therefore an earlier feeding hour may be appropriate. Young children are unable to sit through a long meal and become restless and disruptive. This is particularly common when children are brought to the table just after active play. Calling them in 15 minutes before mealtime allows them to get ready for eating while settling down their active minds and bodies.

Frequent, nutritious, planned snacks can replace a meal; however, these should not replace a regular sit-down meal. “Grazing”—nibbling and snacking—is a good way to ensure proper nutrition, provided that appropriate foods are offered and this does not fill up the child just prior to a regular meal. Between-meal snacks can provide significant nutrition, especially calories, protein, carbohydrate, calcium, and vitamin C. For snacks, parents can place several small pieces of food (carrot sticks, cheese blocks, raisins, crackers, sliced cold meat, apple slices) in an ice cube tray for a pick-and-choose menu. Toddlers like to eat with their fingers and enjoy foods of different colors and shapes (Fig. 14-7).

The method of serving food also takes on more importance during this period. Toddlers need to feel in control and to have a sense of achievement. Giving them large, adult-size portions contributes to their feeling overwhelmed. In general, what is eaten is much more significant than how much is consumed. Small amounts of meat and vegetables supply greater food value than a large consumption of bread or potato. Parents can provide substitutions for foods children do not enjoy, although this practice should not cater to all their desires.

Serving sizes need to be appropriate for age. It is often a good idea to offer less than toddlers may eat and let the child ask for more. A general guide to the serving size of food is 1 tbsp of solid food per year of age or one fourth to one third the adult portion size. Use the tablespoon guide for easily measured foods such as vegetables or rice. Use the fraction guide for milk, bread, or fruit.

The ritualism of this age also dictates certain principles in feeding practices. Toddlers like to have the same dish, cup, or spoon every time they eat. They may reject a favorite food simply because it is served in a different dish. If one food touches another, they often refuse to eat it. Mixed foods, such as stews or casseroles, are rarely favorites. Because toddlers have unpredictable table manners, it is best to use plastic dishes and cups, for both economic and safety reasons. For some children a regular mealtime schedule also contributes to their desire and need for predictability and ritualism.

Appetite and food preferences are sporadic during these years. A child may enjoy one food for 3 days in a row and then suddenly refuse to eat it again for days. Such food fads (or “jags”) do not ensure a well-balanced diet, but attempts to alter them are met with resentment and obstinacy. It is preferable to accept such extremes and offer other foods in small portions. Generally, the child will choose another “favorite food” that may compensate for the nutritional inadequacy.

Developmentally, by 12 months of age most children are eating the same food prepared for the rest of the family. Some may have mastered using a cup with occasional spilling, although most cannot adeptly use a spoon until 18 months of age or later (Table 14-3) and generally prefer using their fingers. Some children find weaning easy and voluntarily relinquish the breast or bottle by the first birthday. Others are unable to give up that pleasure and require a bottle before bedtime or occasionally during the day. Allowing children to give up the bottle when they are ready is preferable to forcing the issue.

This period can be trying for parents and child alike. Because eating habits established in early life affect not only the child’s future eating habits but also the child’s health as an adolescent and adult, it is recommended that toddlers not be forced to eat foods they are reluctant to eat. Evidence indicates that toddlers are able to regulate their hunger and satiety needs internally and that forcing foods during this period may lead to future eating problems (Cathey and Gaylord, 2004).

Regular Dental Examinations

The American Academy of Pediatric Dentistry (2009) now recommends that every child have an oral health examination by a practitioner by the age of 12 months. Initial visits to the dentist should be nontraumatizing. Because toddlers react negatively to new and potentially frightening experiences, the initial visit can center around meeting the dentist, seeing the equipment, and sitting in the chair. If the child is cooperative, the dentist may just look at the teeth but reserve a more thorough examination for another visit. Modeling, in which the child observes procedures performed on the parent or a cooperative sibling, can also be effective but may not work with all toddlers.

Removal of Plaque

Oral hygiene measures should be implemented as noted above to remove plaque, soft bacterial deposits that adhere to the teeth and cause dental caries (decay or cavities) and periodontal (gum) disease. Poor oral hygiene and poor dietary habits are associated with the development of caries in children. The most effective methods for plaque removal are brushing and flossing. Several brushing techniques exist, although there is no universal agreement regarding the best method. One that is suitable for cleaning the primary teeth is the scrub method. The tips of the bristles are placed firmly at a 45-degree angle against the teeth and gums and moved back and forth in a vibratory motion. The ends of the bristles should be wiggling but not moving forcefully back and forth, which can damage the gums and enamel. All the surfaces of the teeth are cleaned in this manner except the lingual (inner) surfaces of the anterior teeth. To clean these surfaces, the toothbrush is placed vertical to the teeth and moved up and down. Only a few teeth are brushed at one time, using six to eight strokes for each section. A systematic approach is used so that all surfaces are thoroughly cleaned (Fig. 14-8).

For young children, the most effective cleaning is done by parents (Fig. 14-9). Several positions can be used that facilitate access to the mouth and help stabilize the head for comfort:

Use one hand to cup the chin and the other to brush the teeth. For easier access to back teeth, hold the mouth partially open.

For effective cleaning, a small toothbrush with soft, rounded, multitufted nylon bristles that are short and uniform in length is recommended. Nylon bristles dry more rapidly after use and retain their shape better than natural bristles. Toothbrushes are replaced as soon as the bristles are frayed or bent. With young children, brushing may be more easily accomplished using only water, since many children dislike the foam from toothpaste and the foam interferes with visibility. There is also the danger of swallowing fluoridated toothpaste (see following discussion under Fluoride). When using toothpaste, children should select the flavor they like to encourage the brushing habit.

After the teeth have been cleaned, the teeth are flossed with dental floss to remove plaque and debris from between the teeth and below the gum margin, where brushing is ineffective. Since young children do not have the dexterity to manipulate the floss, parents are taught the procedure.

A disclosing agent is helpful in identifying those areas of the teeth where plaque accumulates. It also helps motivate children to clean their teeth because plaque is difficult to see. After cleaning, the mouth is inspected to ensure that all traces of plaque have been removed. Where plaque remains, the teeth are rebrushed.

Ideally, the teeth should be cleaned after each meal and especially before bedtime, and the child should be given nothing to eat or drink after the night brushing except water. When brushing is impractical, the “swish-and-swallow” method of cleaning the mouth is taught: with a mouthful of water the child rinses the mouth and swallows, repeating the procedure three or four times.*

Fluoride

Consider fluoride supplementation for any child over the age of 6 months whose drinking water is deficient in fluoride. Supplementation based on fluoride concentration of water supply at less than 0.3 ppm is 0.25 mg for a child age 6 months to 3 years of age (American Academy of Pediatric Dentistry, 2009).

Fluoride, a mineral, is found in water, foods, or drinks in which fluoridated water is used as part of the processing system. Because the water fluoridation process and manufacturing of fluoride toothpaste are almost impossible to standardize in the United States, the dosage of fluoride supplements has been lowered to reduce the incidence of fluorosis, a condition characterized by an increase in the degree and extent of the enamel’s porosity (Table 14-4). Increased fluoride ingestion leads to enamel protein retention, hypomineralization of the enamel and dentin, and disturbance of crystal formation. Fluorosis can cause staining of the teeth (chalky white to yellow or brown), barely discernible white fiberlike lines, or, in more severe forms, spots to gray-brown stains or pitted areas (see Community Focus box).

Fluoride toothpaste reduces caries even further when the water supply is fluoridated, since it imparts a topical benefit to the teeth. However, a concern with fluoride toothpaste used in conjunction with other sources of fluoride is excessive fluoride ingestion by young children and the possibility of fluorosis. To prevent excessive intake, only a smear of toothpaste should be used for children under 2 years and for children aged 2 to 5 years a pea-sized amount (0.25 g) of toothpaste (American Academy of Pediatric Dentistry, 2009). Fluoride may also be recommended by the dentist as a mouth rinse for children old enough to swish the rinse in the mouth and spit it out instead of swallowing the rinse. Although the prevalence of dental enamel fluorosis in children has increased over the past 30 years (American Academy of Pediatrics, 2009), a specific cause in each case has yet to be identified (Erdal and Buchanan, 2005). There are concerns that the increased amount of fluoride found in community drinking water, in addition to fluoride in water-based beverages such as reconstituted formula, may be a contributing factor (American Academy of Pediatrics, 2009; Marshall, Levy, Warren, et al, 2004). Ismail and Hasson (2008) examined a number of studies and found only weak and inconsistent evidence that fluoride supplements prevent dental caries in primary teeth, but the effect on permanent teeth was significant; the researchers also noted that the children under 3 years of age who used fluoride supplements had a mild to moderate increase in dental fluorosis.

The American Academy of Pediatrics (2009) does not recommend the use of fluoridated toothpaste in children 2 years of age and younger.

Caution parents against regular use of fluoridated water or infant beverages containing fluoride if the community water supply already has an adequate amount of fluoride (see Table 14-4). Fluorosis is not a health concern but may be a cosmetic concern for affected children. Ingesting excessive fluoride after age 5 or 6 years does not result in fluorosis, since the permanent teeth, except for the third-year molars, are completely calcified.

If children primarily consume water from another source other than the public water supply (e.g., bottled water), a fluoride supplement or rinse may be required. Professional fluoride treatments may be administered to children at risk for caries at routine dental visits as a preventive measure (American Academy of Pediatric Dentistry, 2009).

Nurses have a responsibility to ensure an optimum fluoride regimen for children and to counsel families regarding correct use of fluoride mouth rinses and supplements. The nurse should have knowledge of the fluoride content of the community water supply and instruct parents regarding correct administration of fluoride supplements. All fluoride products (toothpaste, supplements, and rinse) need to be stored away from young children to prevent poisoning. Fluoride toxicity may occur if significant amounts of fluoride are ingested; a toxic dose for a 12-month-old weighing 10 kg (22 lb) would be 50 ml of a 1000 ppm fluoride toothpaste (American Academy of Pediatrics, 2009). If the water supply is fluoridated, encourage parents to use tap water to prepare drinks and foods.

Dietary Factors

Nutrition is critical to developing good teeth because the carious process depends primarily on fermentable sugars, especially sucrose. Refined table sugar is not the only concentrated sweet food that is cariogenic. Natural foods, including honey, molasses, corn syrup, and dried fruits such as raisins, are highly cariogenic. Complex carbohydrates, such as breads, potatoes, and pasta, also contribute to caries because they lower the plaque pH. (See Dental Disorders, Chapter 18.)

The more cariogenic foods are those that are sticky or hard because they remain in the mouth longer. Thus sucking on lollipops is more cariogenic than eating a chocolate bar. The consumption of sweetened carbonated beverages has increased among children and these drinks have significant potential for causing caries. Sometimes the source of the sugar is “hidden,” as in numerous prescription and nonprescription drugs and in many popular cereals, including the “all-natural” variety. Reading food labels is essential in identifying and eliminating sources of sucrose. Ideally, parents should eliminate foods containing high amounts of sucrose. However, since this is impractical, some suggestions can be helpful. First, the frequency with which sugar is consumed is more important than the total amount eaten. Sweets are less damaging if consumed immediately after a meal rather than as a snack between meals. When sweets are served as the dessert, the teeth can be cleaned afterward, decreasing the amount of time the sugar is in the mouth.

These suggestions can help parents plan “treats” in a way that is less damaging to the teeth. In addition, parents should be aware of foods that are good snacks and that contribute less to tooth decay. Some snacks do not contribute to tooth decay and may actually protect against it. Aged cheeses, such as cheddar, may alter the pH and retard bacterial growth. Sugarless gum chewed for about 20 minutes after eating may also protect against cavities by stimulating saliva that neutralizes acid, and saliva itself may have caries-protective factors. The artificial sweeteners saccharin and aspartame are noncariogenic, and sorbitol has low cariogenic potential.

A special form of tooth decay in children between 18 months and 3 years of age is early childhood caries (ECC) (historically called nursing caries or baby bottle tooth decay). This often occurs when the child is routinely given a bottle of milk or juice at naptime or bedtime or uses the bottle as a pacifier while awake. Frequent nocturnal breast-feeding for prolonged periods also leads to extensive destruction of the teeth. The practice of coating pacifiers in honey can also contribute to caries and may be a potential source of botulism poisoning. As the sweet liquid pools in the mouth, the teeth are bathed for several hours in this cariogenic environment. Prolonged bottle-feeding well into toddler years in the Mexican-American culture may contribute to significant ECC (Brotanek, Schroer, Valentyn, et al, 2009). In one group prolonging bottle-feeding into toddlerhood was perceived as “buying time” to decrease the child’s crying (Freeman and Stevens, 2008). The maxillary (upper) incisors and sometimes molars are affected most because the mandibular (lower) teeth are protected by the lower lip, tongue, and saliva (Fig. 14-10). Severely decayed teeth may require the application of stainless steel crowns, with or without white fronts, to preserve the spacing until the permanent teeth erupt.

ECC is now considered to be an infectious disease of childhood. There is evidence that Streptococcus mutans is a highly cariogenic bacteria (American Academy of Pediatrics, 2009). One of the early origins of S. mutans is the mother’s saliva; infants of mothers with high counts of the bacteria have a greater incidence of ECC. Therefore it is important to discuss oral hygiene with pregnant women because of its impact on the child’s tooth development. Exposure to tobacco smoke has also been linked to an increased incidence of caries in children (Shenkin, Broffitt, Levy, et al, 2004).

Prevention involves eliminating the bedtime bottle completely, feeding the last bottle before bedtime, substituting a bottle of water for sweet liquids, not using the bottle as a pacifier, and never coating pacifiers in sweet substances. Discourage juice in bottles, especially commercially available ready-to-use bottles, since the beverage is especially damaging because the sugar is more readily converted to acid. Juice should always be in a cup to avoid prolonging the bottle-feeding habit.

Nurses are in an excellent position to counsel parents regarding this habit, especially if it occurs during hospitalization. Although the child may need the comfort of the bottle at this stressful time, nurses can show parents photographs depicting the typical tooth destruction and give them literature about the condition.* Over an extended hospital stay, children can be gradually weaned from the bedtime bottle or given a bottle of water.

Motor Vehicle Injuries

Motor vehicle injuries cause more accidental deaths in all pediatric age-groups after age 1 year than any other type of injury or disease and are responsible for a significant number of all accidental deaths among children ages 1 to 4 years. Many of the deaths are caused by injuries within the car when restraints have not been used or age-related guidelines have not been properly followed. Unrestrained children riding in the vehicle’s front seat are at the highest risk for injury (Durbin, Chen, Smith, et al, 2005). Approved restraints properly installed and applied can reduce the majority of fatalities and injuries (American Academy of Pediatrics, 2010; Schnitzer, 2006).

Skill—Car Seat Safety

Nurses are responsible for educating parents regarding the importance of car restraints and their proper use. Five types of restraints are available: (1) infant-only devices, (2) convertible models for both infants and toddlers, (3) boosters, (4) safety belts, and (5) devices for children with special needs (see Chapter 22). Chapter 12 discusses the infant-type restraints; convertible restraints and boosters are included here. The convertible restraint is suitable for infants in the rearward-facing position (Fig. 14-11). It has been recently recommended that children ride in a convertible seat in a rear-facing position to the highest weight or height allowed by the manufacturer of the seat; this recommendation includes children aged 12 to 23 months of age (Bull and Durbin, 2008).

One study showed that children from birth to 23 months experienced fewer injuries when riding in rear-facing car restraints (Henary, Sherwood, Crandall, et al, 2007). Another study indicated that children 0 to 3 years of age riding properly restrained in the middle of the back seat had a 43% lower risk of injury than children riding in the outboard (window) seat during a crash (Kallan, Durbin, and Arbogast, 2008).

A convertible safety seat is positioned semireclined and facing the rear of the car for a child younger than 1 year weighing less than 9 kg (20 lb). The seat is positioned upright and facing forward for an older and heavier child (up to 18 kg [40 lb]). Convertible safety seats should be used until the child weighs at least 13.6 kg (30 lb) or more regardless of age and as long as the child fits properly into the seat (American Academy of Pediatrics, 2010). Convertible restraints use different types of harness systems: a five-point harness that consists of a strap over each shoulder, one on each side of the pelvis, and one between the legs (all five come together at a common buckle); and a padded shield that uses shoulder straps attached to a shield that is held in place by a crotch strap. With both the infant and toddler restraints, it is important not to add extra blankets, head cushions, or padding between the child and the restraint straps that did not come as original equipment because these “add-ons” create spaces of air between the child and the restraint and decrease support for the back, head, and neck.

Cars with free-sliding latch plates on the lap or shoulder belt require the use of a metal locking clip to keep the belt in a tight-holding position. The locking clip is threaded onto the belt above the latch plate (Fig. 14-12, A). If parents have newer cars with automatic lap and shoulder belts, they need to have additional lap belts installed to properly secure the restraint.

Booster seats are not restraint systems like the convertible devices because they depend on the vehicle belts to hold the child and booster seat in place. Three booster models have been approved by the National Highway Traffic Safety Administration: the high-back belt-positioning seat (Fig. 14-12, B), which provides head and neck support for the child riding in a vehicle seat without a head rest; the no-back belt-positioning seat, which should be used only if the vehicle seat has a head rest; and a combination seat, which converts from a forward-facing toddler seat to a booster seat. This last model is equipped with a harness for use by toddlers; the harness may be removed and a shoulder-lap belt used when the child outgrows the harness. Booster seats are used for children who are less than 145 cm (4 feet, 9 inches) tall and who weigh 15.9 kg to 36.3 kg (35 to 80 lb, depending on the type of booster seat), typically those between 4 and 8 years of age (National Highway Traffic Safety Administration, 2009). A booster seat should be used until the child is able to sit against the back of the seat with feet hanging down and legs bent at the knees. The belt-positioning booster model raises a child higher in the seat, moving the shoulder part of the belt off the neck and the lap portion of the belt off the abdomen onto the pelvis. Children who outgrow the convertible restraint may still be able to ride safely in a booster seat until the midpoint of the head is higher than the vehicle seat back.

Children should use specially designed car restraints until they are 145 cm (4 feet, 9 inches) in height or are 8 to 12 years old (American Academy of Pediatrics, 2010). Shoulder-lap safety belts should be worn low on the hips, snug, and not on the abdominal area. Children should be taught to sit up straight to allow for proper fit. The shoulder belt is used only if it does not cross the child’s neck or face (see Family-Centered Care box).

Shoulder-only automatic belts are designed to protect adults. Children should use the manual shoulder belts in the rear seat. Air bags do not take the place of child safety seats or seat belts and can be lethal to young children. The safest area of the car for children is the back seat. Children who must ride in the passenger side of the front seat with an air bag should be positioned as far back as possible.

Built-in seats are available in some cars and vans. They may be used for children who are at least 1 year of age and weigh at least 9 kg (20 lb). Built-in seats eliminate installation problems. However, weight and height limits vary. Reinforce that owners must verify with vehicle manufacturers details about built-in seats.

For any restraint to be effective, it must be used consistently and properly. Examples of misuse include misrouting the vehicle seat belt through the restraint; failing to use the vehicle seat belt to secure the restraint; failing to use a tether strap; failing to use the restraint’s harness system; and incorrectly positioning the child, especially by facing infants forward instead of rearward. To address these issues, nurses must stress correct use of car restraints and rules that ensure compliance (see Family-Centered Care box). Children riding in car safety seats are generally much better behaved than children left unrestrained, which can be a major benefit to parents and should be emphasized as an additional advantage of restraints. Additional information about child safety restraints is available from various sources.*

The LATCH (Lower Anchors and Tethers for Children) universal child safety seat system was implemented as a requirement starting in 2002 for all new automobiles and child safety seats. This system provides uniform anchorage consisting of two lower anchorages and one upper anchorage in the rear seat of the vehicle (Fig. 14-13). When used appropriately, the top anchor (tether) strap prevents the child from pitching forward in a crash. If the tether strap is not used, up to 90% of the restraint’s protection is lost. Instructions for proper installation of the tether strap and permanent bracket are included with the car restraint. New child safety seats have a hook, buckle, strap, or other connector that attaches to the anchorage. Seat belts are no longer used to anchor child safety seats to newer vehicles. The first phase required all new cars to have an upper anchorage. After fall 2002, all new cars were required to have the entire LATCH system.

Children with special needs may require a restraint system that secures them appropriately in the event of a crash. Examples of such devices include car bed restraints for infants who cannot tolerate a semireclining position and specially adapted molded-plastic chairs for children who have spica casts. The E-Z-On vest is a special safety harness for larger children with poor trunk control. Additional safety restraints and a list of distributors are available at the SafetyBeltSafe U.S.A. website (www.carseat.org). See also Chapter 27 for discussion of preterm infants being discharged home and car seat evaluation.

Children should never ride in the open back of a truck. The danger of falls can be compounded by another vehicle striking the child or by the truck rolling over. In addition, leaving children unsupervised in a parked vehicle, especially in a private driveway, provides an opportunity for a child to release the brake or put the car in gear. The child also can be injured from a collision to or a fall from a bicycle-towed trailer or bicycle-mounted child seat.

Toddlers are often involved in pedestrian traffic injuries. Because of their gross motor skills of walking, running, and climbing and their fine motor skills of opening doors and fence gates, they are likely to be in hazardous areas unsupervised. Unaware of danger and unable to estimate the speed of a car, children are hit by moving vehicles. Running after a ball, playing in a pile of leaves or snow or inside a cardboard box, riding a tricycle, and playing behind a parked car or near the curb are common activities that may result in a vehicular tragedy.

A precaution when children are playing in driveways is to attach to the tricycle a pole with a bright flag that is high enough to be visible through an automobile’s back window. Other safeguards include a device that beeps when the vehicle is driven in reverse to alert children to the oncoming car, van, or truck. Some vehicles now include a rearview video camera. Physical barriers (fences or barricades) limiting children from playing near vehicles help prevent these injuries.

Another type of injury that has become more common occurs when children crawl into an open trunk and pull it closed. Asphyxia may occur in such cases; therefore car trunks should not be left open when children are unsupervised. Some cars are equipped with a safety switch that can be activated from inside the trunk to open a closed trunk door.

Another automobile-related hazard for toddlers is overheating (hyperthermia) and subsequent death when left in a vehicle in hot weather (>27° C [80° F]). Small children dissipate heat poorly, and an increase in body temperature can cause death in a few hours. From 1998 to 2009 (July), a total of 431 children died from hyperthermia when left alone in a parked car; in 2008 the total number of child deaths was 43, and it is estimated that an average of 37 children die each year from overheating in a car (McLaren, Null, and Quinn, 2005; Null, 2009). It is estimated that with the ambient temperature at 22° to 35.5° C (72° to 96° F), the vehicle interior temperature rises by 10.5° to 11° C (19° to 20° F) for each 10 minutes, even with a window cracked (Null, 2009). In a study of 171 child fatalities from overheating in a car, 50% of adults who left a child in a car either forgot or were unaware that the child was still in the car. A significant number of those children (32) were left by family members who intended to take the child to daycare but forgot the child in the car at the workplace; 22 children were left in the car by a daycare worker or driver (Guard and Gallagher, 2005). Parents are cautioned against leaving infants alone in a vehicle for any reason.

Preventing vehicular injuries involves protecting and educating children about the danger of moving or parked vehicles. Although preschool children are too young to be trusted to always obey, the parent should emphasize looking for moving vehicles before crossing the street, recognizing the stop and go colors of traffic lights, and following traffic officers’ signals. Physical barriers limiting children from playing near vehicles help prevent these injuries. Most important, what is preached must be practiced. Children learn through imitation, and consistency reinforces learning.

Drowning

Drowning ranks second among boys and third among girls ages 1 to 4 years as a cause of accidental death. Drowning rates in toddlers have changed little despite prevention strategies. With well-developed skills of locomotion, toddlers are able to reach potentially dangerous areas, such as bathtubs, swimming pools, wading pools, irrigation ditches, post holes, hot tubs, ponds, and lakes. Even unlikely sources of water, such as toilets and 5-gallon buckets, are dangerous (Brenner and American Academy of Pediatrics, 2003). As inquisitive toddlers lean over the rim of the receptacle, their large, heavy head, limited strength, and poor coordination make it difficult for them to extricate themselves. Therefore water in containers should be removed immediately after use. Toddlers’ intense drive for exploration and investigation, combined with an unawareness of the danger of water and their helplessness in water, makes drowning always a threat. Also, death occurs within minutes, diminishing the chance for rescue and survival. Near-drowning is one of the leading causes of a vegetative state in young children. Half of all children who receive cardiopulmonary resuscitation (CPR) and survive have permanent neurologic impairment (Brenner and American Academy of Pediatrics, 2003).

Supervising children when near any source of water is essential. Participation in formal swimming lessons was associated with an 88% reduction in the risk of drowning in one study of 1- to 4-year-old children (Brenner, Taneja, Haynie, et al, 2009). In contrast, previously it was suggested that teaching children under age 4 years to swim does not provide “drown proofing” and may lead to a false sense of security (Brenner and American Academy of Pediatrics, 2003). Four-sided fencing should surround the pool and have a child-proof latch. Parents should know CPR and have a telephone and U.S. Coast Guard–approved emergency equipment at the poolside.

Burns

Toddlers’ ability to climb, stretch, and reach objects above their heads makes any hot surface a potential source of danger. Children pulling pots with hot liquids, especially oil and grease, on top of themselves are a major source of burns. As a precaution, turn pot handles toward the back of the stove, and electric pots (e.g., coffee maker, frying pan, slow cooker, popcorn maker), including cords, should be placed out of reach. Ideally, the knobs for controlling the range burners should be out of reach, not on the front panel where nimble fingers can turn them on and accidentally touch the hot burner.

Other sources of heat, such as radiators, fireplaces, accessible furnaces, kerosene heaters, or wood-burning stoves, should have guards placed in front of them. The tops of some of these heaters are designed to become hot enough to boil water to provide humidity. They are hazardous if touched or if the pan of water is spilled. Portable electric heaters must be placed in a high area, well out of reach of climbing young children.

Hot objects such as candles, incense, hot embers and ashes, cigarettes, pots of tea or coffee, or irons must be placed away from children. Ashtrays with a center well are preferred to prevent the cigarette from falling off the rim, and adults should try not to smoke, cook, or drink hot liquids when children are nearby. If tablecloths are used, place the edges out of reach to prevent injuries from both burns and falling objects. When children are near smoldering fires (campfires, brush fires, fires buried on the beach), wearing shoes can help protect the feet from burns.

Flame burns represent one of the most fatal types of burns and commonly occur when children play with matches and accidentally set themselves (and the home) on fire (Fig. 14-14). All matches must be stored safely away from children, and parents need to teach children the dangers of playing with matches. In addition, all homes should have smoke detectors installed to alert the occupants of a fire. A safety plan for immediate escape is also essential.

Electrical burns represent an immediate danger to children. With the ability to manipulate small, thin objects, they are able to insert hairpins or other conductive articles into electrical sockets. Young toddlers may explore outlets and wires by mouthing them. Because saliva is an excellent conductor, the chance for a severe circumoral electrical burn is great. Electrical outlets should have protective guards plugged into them when not in use or be made inaccessible by placing furniture in front of them when feasible (Fig. 14-15). Children should not be allowed to play with electrical cords, appliances, or batteries, which should be kept out of reach as much as possible.

Scald burns are the most common type of thermal injury in children, especially 1- and 2-year-olds (Drago, 2005). Scalding often occurs because the child is reaching to a stove or other surface and pulling hot water onto herself or himself, or because the child has spilled a hot liquid container (such as a parent’s coffee or tea) onto herself or himself (Drago, 2005). Scalding can also occur from children coming into contact with high-temperature tap water by turning on the hot-water faucet, falling into a bathtub of hot water, or suffering deliberate abuse. Besides the obvious prevention of always supervising children when they are near tap water and checking bathwater temperatures, a recommended passive prevention is to set the water heater to limit household water temperatures to less than 49° C (120° F). At this temperature it takes 10 minutes for exposure to the water to cause a full-thickness burn. Conversely, water temperatures of 54° C (130° F), the usual setting of most water heaters, expose household members to the risk of full-thickness burns within 30 seconds. Nurses can help prevent such burns by advising parents of this common household danger and recommending that they adjust the water heater to a safe temperature. An easy-to-read hot-water gauge that changes color to show water temperatures between 49° and 65.5° C (120° and 150° F) is available; it shows “hot,” “cool,” or “OK” water temperature. A special device can also be added to the faucet that reduces the water flow if the set temperature is reached.

Sunburns are a special concern for this age group. Children spend a large amount of time outdoors, and their increased mobility makes it difficult to prevent sun exposure. Sunburn can be prevented by applying a sunscreen with a sun protection factor (SPF) of 15 or greater, dressing in protective clothing (wide-brimmed hat, protective cotton clothing with a tight weave), and avoiding sun exposure between 10 am and 2 pm.

Poisoning

Although in many instances poisoning does not result in death, it may cause significant morbidity, such as esophageal stricture from lye ingestion. Mouthing activity increases toddlers’ risk of poisoning; exploring objects by tasting them is part of children’s curious investigation. Because of their curious nature, children under 6 years of age are more likely to eat unusual, distasteful substances. Recent attention has focused on the use of over-the-counter (OTC) medications used for cough and colds as a common cause of accidental poisonous ingestion in toddlers. Ingestion of acetaminophen is also a common cause of morbidity because it is found in many combination OTC products; caregivers may unknowingly administer a dose of acetaminophen in addition to an OTC drug containing the product without knowing the danger.

Although young children may be able to identify some items as poisonous, they do not understand the toxic effects of ingesting excessive amounts of a familiar drug, such as vitamins or iron. Many household products, medications, and plants can be poisonous if swallowed, if in contact with the skin or eyes, or if inhaled. Almost every nonfood substance is potentially harmful, and by 2 years of age toddlers are able to climb most heights, open most drawers or closets, and unscrew most lids. By trial and error, they also manage to undo tops of bottles, plastic containers, aerosol cans, and jars.

However, they are most likely to ingest substances that are on their level, such as plants, cleaning agents stored under sinks, rat poison, or diaper pail deodorants, especially when stored in the kitchen, bathroom, laundry, or garage. Child-resistant tops are required on some substances, such as prescription drugs, but many young children have opened such “safe” caps. In addition, pharmacists often transfer drugs to regular containers for the elderly, who may have difficulty with child-resistant closures. Cosmetics and drugs found in a purse are common agents ingested by toddlers.

The major reason for poisoning is improper storage (Fig. 14-16). The guidelines suggested in Chapter 12 apply to children in this age-group as well. However, unlike infants, who are unable to reach certain heights or unlatch inventive locks, young children manage to find access to many high-level, tight-security places. For this age-group, only a locked cabinet is safe.

Ipecac syrup is no longer recommended as an antidote for poisoning in children (American Academy of Pediatrics, 2003) because it has not been shown to improve the eventual outcome in affected children and may prolong the incidence of vomiting when other ingestion therapies are necessary. (See Evidence-Based Practice box: Gastric Lavage in Children, Chapter 16.)

Parents should have ready access to the telephone number for the poison control center and be prepared to act on the center’s advice.* Emergency and preventive measures for accidental poisoning are in Chapter 16.

Falls

Falls are still a hazard to children in this age-group, although by the later part of early childhood, gross and fine motor skills are well developed, decreasing the incidence of falls down stairs or from chairs. However, playground injuries are common. Children need to learn safety at play areas, such as no horseplay on high slides or jungle gyms, sitting on swings, and staying away from moving swings.

The climbing and running activity of the typical toddler is complicated by total neglect for and lack of appreciation of danger, immature coordination, and a high center of gravity. Falling from furniture is a major cause of injury, with more children in this age-group sustaining head injuries than older children. Gates must be placed at both ends of stairs. Accessible windows that are left open during warm weather must be guarded with a rail. Falling from open windows is a major cause of accidental death in urban lower socioeconomic groups; screens are not designed to prevent falls. Doors leading to stairwells or porches must be locked. A convenient type of lock is a sliding bar or hook that can be attached to the door and frame at a level higher than the child can reach, provided that inventive youngsters do not pull a chair over to unlatch the device.

Another site of falls is from cribs and vehicles. In addition to crib rails being fully raised, the mattress should remain at the lowest position, and toys or bumper pads that may be used as steps to climb out should be removed. Ideally, the floor should be carpeted. Once children reach a height of 89 cm (35 inches), they should sleep in a bed rather than a crib. If a bunk bed is selected, parents should be aware of possible dangers: falls and head entrapment between the mattress and guardrail or between the supporting mattress slats. If the beds are constructed of tubular metal or if the brackets holding the mattress are metal, parents should check for breaks or cracks in the metal and welds, which may lead to collapse and injury. Children who sleep on the top bunk should be 6 years or older.

Children can fall from high chairs, shopping carts, carriages, and car seats if not properly restrained or if balance changes when the place where they are sitting is weighed down with heavy objects. Therefore proper restraint and adequate supervision are essential.

Clothing can also increase the chance of falling. Slippery shoes or socks, rubber-soled shoes that “catch” on the floor and rug, and loose or cuffed pants can easily make a child fall. Simple safety measures, such as checking clothing and shoes, keeping shoelaces tied with double knots, or using self-adhering closures, can prevent such needless injuries.

Falls in hospitalized children have received little attention in the scientific literature but are known to occur. Research is currently in progress to identify fall risk factors specific to hospitalized children.

Aspiration and Suffocation

Usually by 1 year of age children chew well, but they may have difficulty with large pieces of food, such as meat or whole hot dogs, and with hard foods, such as nuts or dried beans. Small items such as colored beads, green peas, pellets, or beans are often placed into the nose by toddlers and may present a danger if aspirated into the airway. Young children cannot discard pits from fruit or bones from fish like older children. Therefore implement the same precautions as discussed for infants regarding food selection. (See Chapter 12.)

Play objects for toddlers must still be chosen with an awareness of the danger of small parts. Large, sturdy toys without sharp edges or removable parts are safest. Coins, paper clips, pull tabs on cans, thumbtacks, nails, screws, jewelry (especially pierced earrings), and all types of pins are common household objects that can cause significant harm if swallowed or aspirated. Because of the danger of aspiration, parents should know emergency procedures for choking. (See Airway Obstruction, Chapter 31.)

Suffocation is less frequent from causes seen during infancy but is an ever-present threat from old refrigerators, car trunks, ovens, and other large appliances. Toddlers can climb inside these appliances and, if they close the door behind them, can become trapped inside. Discarding old appliances and removing all doors during storage prevents such tragic injuries. Toddlers may also suffocate when toy boxes with heavy, hinged lids accidentally close on their head or neck. Advise parents of this danger and encourage them to buy storage chests with lightweight, removable covers.

Bodily Harm

Toddlers are still clumsy in many of their skills and can seriously harm themselves when walking while holding a sharp or pointed object or having food or objects such as spoons in their mouths. Preventing such occurrences is the best approach with toddlers. Teach the child that, when walking with a pointed object, such as a fork, knife, or scissors, he or she needs to hold the pointed end away from the face. Dangerous garden or workshop equipment and all firearms should be stored in a locked cabinet. Power lawn mowers are especially dangerous, and young children should not be allowed in an area where a mower is being used, nor should they be taken for a ride on a mower or allowed to operate the device.

Toddlers are often unable to understand that all pets are not as safe as their own; because of the toddlers’ height, they are often at the eye level of some dogs and may be bitten on the face. It is imperative to teach pet safety to toddlers and keep animals at a safe distance because even the most loving pet may perceive a threat and react accordingly.

Safety education should include respect for firearms and their proper and appropriate use, including nonpowder guns, such as air guns, rifles (BB and pellet), and paintball guns, which can cause serious penetrating injuries. Firearm safety devices such as a trigger locks and personalized locks are necessary to prevent unintentional firing of guns and subsequent injuries or fatalities.

Toys can be a source of danger, and safety must be a prime consideration when selecting toys. Most toys have age ranges written on them to designate their safety, but parents should also consider the specific child’s readiness.

Strategies for ensuring safety in households with toddlers include the usual precautions recommended for any age-group (see Family-Centered Care box). An additional safeguard for young children is the use of safety glass in doors, windows, and tabletops and the application of decals on glassed areas to lessen the likelihood of running through glass. Also, children should not be allowed to run, jump, wrestle, or play ball in areas where glass litter may be a hazard. (See Bodily Damage, Chapter 12; Mammal Bites, Chapter 18.)

• The toddler stage, extending over ages 12 to 36 months, is a period of intense exploration of the environment.

• Biologic development during the toddler years is characterized by the acquisition of fine and gross motor skills that allow children to master a wide variety of activities.

• Although most of the physiologic systems are mature by the end of toddlerhood, development of certain areas of the brain is still occurring, allowing for greater intellectual capacity.

• Locomotion is the major gross motor skill acquired during toddlerhood, followed by increased eye-hand coordination.

• Specific tasks in the psychosocial development of a toddler include differentiating self from others, tolerating separation from parent, coping with delayed gratification, controlling bodily functions, acquiring socially acceptable behavior, communicating verbally, and interacting with others in a less egocentric manner.

• According to Erikson, the major developmental task of toddlerhood is acquiring a sense of autonomy while overcoming a sense of doubt and shame.

• In Piaget’s sensorimotor and preconceptual phases of development, the toddler experiments by incorporating the old learning of secondary circular reactions with new skills and applies this knowledge to new situations. The toddler experiences the beginning of rational judgment, an understanding of causal relationships, and discovery of objects as objects.

• Preconceptual thought is characterized by centration, global organization of thought processes, animism, and irreversibility.

• Language is the major cognitive achievement in toddlerhood.

• The most striking characteristic of language development during early childhood is the increasing level of comprehension.

• Discipline, or a punishment-obedience orientation, aids in children’s moral development.

• Development of body image occurs with increasing motor ability, at which point toddlers recognize the importance and capacity of body parts.

• The two phases of differentiation of self from significant others are separation and individuation.

• Parental concerns during the toddler years include toilet training, sibling rivalry, temper tantrums and negativism, and stress.

• Nutrition is important at this stage because eating habits established in toddlerhood tend to have lasting effects in subsequent years.

• Regular dental examinations, fluoride supplementation, removal of plaque, and provision of foods and beverages that have low cariogenic potential promote optimum dental health.

• Because of increased locomotion, toddlers are at high risk for sustaining injuries. Fatal injuries are primarily the result of motor vehicle accidents, drownings, and burns.

• Drowning was the second leading cause of accidental death in children ages 1 to 4 between 2000 and 2006.

• Children should never be left alone in a car when the environmental temperature is above 27° C (80° F).