Pediatrics Review: Toddlers (Ages 2 to 3 Years)

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DANGER SIGNALS

Neuroblastoma

Most common presentation is a painful abdominal (retroperitoneal or hepatic) mass that is fixed, firm, irregular, and frequently crosses the midline. The most common site is the adrenal medulla (sits on top of the kidneys). About half of patients present with metastatic disease. May be accompanied by weight loss, fever, Horner’s syndrome (miosis, ptosis, anhidrosis), periorbital ecchymoses (“racoon eyes”), bone pain, hypertension, others. Most are diagnosed in children between the ages of 1 and 4 years. Elevated urinary catecholamines and anemia. Initial imaging test is the ultrasound. Refer to nephrologist.

Wilms’ Tumor (Nephroblastoma)

Asymptomatic abdominal mass that extends from the flank toward the midline. The nontender and smooth mass rarely crosses the midline (of the abdomen). Some patients have abdominal pain and hematuria. One fourth of patients have hypertension. Higher incidence in Black, female children. Peak age is 2 to 3 years. The most common renal malignancy in children. While performing the abdominal exam, palpate gently to avoid rupturing the renal capsule (causes bleeding and seeding of abdomen with cancer cells). Initial imaging test is an abdominal ultrasound.

Epiglottitis

Acute and rapid onset of high fever, chills, and toxicity. Child complains of severe sore throat and drooling saliva. Will not eat or drink, muffled (hot potato) voice, and anxiety. Characteristic sitting posture with hyperextended neck with open-mouth breathing. Stridor, tachycardia, and tachypnea. Usually occurs between ages 2 and 6 years. Before the Hib vaccine was used, most cases were due to Haemophilus influenzae type b (Hib; 75%). Other pathogens are Staphylococcus aureus, Streptococcus pyogenes, fungi, others. Now rare due to the Hib conjugate vaccine. Prophylaxis with rifampin (duration is 4 days). for close contacts. Reportable disease. A medical emergency. Call 911.

Osteomyelitis

More common in infants and children. Infected bone or joint is red, swollen, warm, and tender to touch. Patient is febrile and irritable. If patient walks with a limp, may have infection on the hip, knee, or leg. If infection involves the upper extremities, will favor infected limb (avoids 412using the limb). Growth plate infection results in growth stunting of the affected limb. Refer for hospitalization and high-dose antibiotics.

Figure 21.1 Periorbital cellulitis. This image can be found in color in the app.

Source: Wikimedia. Afrodriguezg.

Orbital Cellulitis

Young child complains of abrupt onset of deep eye pain that is aggravated by eye movements and is accompanied by a high fever and chills. Affected eye will appear to be bulging (proptosis or exophthalmos). Extraocular eye movements (EOMs) exam will be abnormal due to ophthalmoplegia (limited movement of eyeball) form infection of the ocular fat pads and muscles. More common in younger children. Ethmoid sinusitis is more likely to cause orbital cellulitis compared with frontal/maxillary sinusitis. Can be life-threatening. A serious complication of rhinosinusitis, acute otitis media, or dental infections. Refer to emergency department (ED). CT scan or MRI is done in the ED.

Pretectal Cellulitis (Periorbital Cellulitis; Figure 21.1)

More common than orbital cellulitis. An infection of the anterior portion of the eyelid that does not involve the orbit/globe or the eyes. Rarely causes serious complications (compared with orbital cellulitis). Younger children are most likely to be affected. Young child complains of the new onset of red swollen eyelids and eye pain (sometimes none). Eye movements do not cause pain and EOM exam is normal (both are abnormal with orbital cellulitis). No visual impairment. May be hard to distinguish from orbital cellulitis. Refer to ED.

Child Abuse

The majority of perpetrators are parents (82%), with other relatives accounting for 6%. About 16% of the perpetrators are persons whom the child is exposed to such as day care staff and unmarried partners. Multiple healed skull and/or rib fractures. Greenstick fractures. Bruises in the trunk area.

Delay in seeking medical care. Explanations for injuries inconsistent with presentation. Infants and children who are developmentally or physically disabled are at higher risk. Nurses, nurse practitioners, and several other professionals are required to report suspected or actual child abuse to authorities.

U.S. Health Statistics: Toddlers

Top Three Causes of Death

Ages 1 to 4 Years

Accidents or unintentional injuries

Congenital and genetic anomalies

Assault (homicide) (Heron, 2016)

413Cancer in Children

Top Three Cancers in Children

Leukemia (34%)

Brain and nervous system tumors (27%)

Neuroblastoma (7%)

The most common cancer in children is leukemia. The most common type of leukemia in children is acute lymphocytic leukemia (ALL). The remaining cases are due to acute myelogenous leukemia (AML). Medulloblastomas are the most common type of childhood brain cancer (most occur before age 10 years). The most common renal malignancy in children is Wilms’ tumor.

GROWTH AND DEVELOPMENT

Table 21.1 summarizes normal and abnormal childhood development from birth through 5 years of age. See Chapter 20 for corresponding discussions of newborn through 1 year, and Chapter 22 for preschool and school-age child, ages 4 and older.

2 Years Old

Language

Speaks in two- to three-word sentences (intelligible mostly by family)

Understands simple commands

Knows first name

Fine Motor

Stacks six cubes

Can copy straight line

414Gross Motor

Goes up stairs using same foot

Runs, jumps, and climbs

Is very active and energetic

Behaviors

Temper tantrums are common at this age

Easily frustrated and says “no” often; oppositional behaviors

May have a favorite stuffed toy (transitional object)

Toilet training is now in progress

Report loss of speech, social skills, or previously learned skills; flapping hands; avoids social interaction (rule out autism)

3 Years Old

Language

Speaks in complete sentences using three to five words

Speech is understood by most strangers

Knows full name, age, sexual identity

Magical thinking is prominent at this age (ages 3–5 years); may have an imaginary friend; a girl may think that she is a fairy with special powers

Fine Motor

Copies a circle (but not a cross)

Can throw a ball overhead

Can stack nine cubes

Gross Motor

Pedals a tricycle

Knows three numbers and three colors

Walks up (ascends) stairs with alternating feet

Behaviors

Freud classified this age as the “Oedipal stage” (phallic stage): The child expresses the desire to marry the parent of the opposite sex; occurs between the ages of 3 and 5 years (preschool)