AGE	PHYSICAL	GROSS-MOTOR	FINE-MOTOR	VOCALIZATION	SOCIALIZATION
15 months	Steady growth in height and weight Head circumference,48 cm (19 in) Weight, 11 kg (24 lb) Height, 78.7 cm (31 in)	Walks without help Cannot throw a ball without falling	Builds tower of two cubes Releases a pellet into a narrow-necked bottle Uses cup well	Says four to six words, including names Understands simple commands Uses “no” while agreeing to request	Less likely to fear strangers Begins to imitate parents, such as cleaning house Has temper tantrums Kisses and hugs parents
18 months	Physiologic anorexia from decreased growth needs Anterior fontanel closed Physiologically able to control sphincters	Runs clumsily, falls often Walks up stairs with one hand held Throws ball overhand without falling Pulls and pushes toys	Builds tower of three to four cubes Turns pages of a book two or three at a time	Says 10 or more words Points to a common object, including two to three body parts	Takes off shoes and socks; unzips Beginning awareness of “my” toy, and so on. May develop dependency on transitional object such as blanket
24 months	Head circumference, 49.5 to 50 cm (19 to 20 in) Chest circumference exceeds head circumference Usual weight gain is 1.8 to 2.7 kg (4 to 6 lb) Usual gain in height is 10 to 12.5 cm (4.5 to 5 in) Adult height, approximately double height at 2 years May have achieved readiness for beginning control of bowel and bladder Primary dentition (16 teeth)	Goes up and down stairs alone with two feet on each step Runs fairly well, with wide stance Picks up object without falling Kicks ball forward without overbalancing	Builds tower of six to seven cubes Aligns two or more cubes like a train Turns pages of book one at a time In drawing, imitates vertical and circular strokes Turns doorknob and unscrews lid	Has vocabulary of approximately 300 words Uses two-word and three-word phrases Says “I,” “me,” “you” Understands directional commands Gives first name; refers to self by name Verbalizes need for toileting, food, or drink Talks incessantly	Stage of parallel play Has sustained attention span Temper tantrums decreasing Pulls people to show them something Increased independence from mother Dresses self in simple clothing
30 months	Birth weight quadrupled Primary dentition (20 teeth) completed May have daytime bowel and bladder control	Jumps with both feet Jumps from chair or step Stands on one foot momentarily Takes a few steps on tiptoe	Builds tower of eight cubes Good hand-finger coordination Draws cross	Gives first and last name Refers to self by appropriate pronoun Uses plurals Names one color	Separates more easily from mother Helps put things away Begins to notice gender differences; knows own gender May attend to toilet needs without help except for wiping

Modified from Hockenberry, M., and Wilson, D. (2007). Wong’s nursing care of infants and children (8th ed.). St. Louis: Elsevier.

Toddlers are curious explorers who get into everything. As each month passes, they gain more control of their bodies. Soon they are walking, running, jumping, and climbing (Figure 7-1). They enjoy repeating these new skills, and with practice, they become less clumsy and awkward. Their desire to touch, taste, smell, and smear leads them into trouble. They quickly discover that much of their conduct alarms their parents. Unlike when they were infants, toddlers find that their parents no longer accept their actions willingly and without question. Toddlers cannot understand the need for restrictions, and, as a result, they revolt. Temper tantrums are common, and behavior is not consistent. Negativism is reflected in unreasonable behavior and by saying “no” frequently. Ritualism is characteristic of toddlers. By making simple tasks into rituals, they increase their sense of security and self-mastery. Dawdling serves essentially the same purpose, and egocentric thinking predominates.

FIGURE 7-1 Older toddlers run with ease.

Developmental Tasks

The developmental tasks seen during this period are based on a continuum of trust established during infancy. Physicians and nurse practitioners can readily focus on age-related tasks at the toddler’s well-visit. Toddlers are now ready to give up total dependence. They become autonomous and seek independence (see discussion on Erikson in Chapter 4). They begin to differentiate themselves from others, particularly from their mother. They learn to delay gratification and to incorporate rudiments of socially acceptable behavior as determined by the limits of their family’s culture. Important self-regulatory functions include toilet independence, eating, sleeping, and perfection of new-found physical skills.

Separation continues to be a major issue with this age group. Toddlers are beginning to separate somewhat from their parents but can tolerate only brief periods of independence and still remain very interested in knowing where their parents are (Figure 7-2). Their greatest fear is separation from their parents. They need to be reassured that when their parents leave, they will return. The younger toddler might exhibit night waking as a response to fear of separation. This same child might use a transitional object (blanket, toy) for consolation when separated from the parent. By 2 years of age, the child still gets upset when separated from the parents, although not as much as before. The nurse should be reminded that separation fears are increased when a child is under stress. So the hospitalized child needs to be supported if the parents are unable to stay. Parents should never “sneak out” on a child. Mastering separation is a normal developmental process. The gradual control of these activities provides toddlers with a sense of mastery and contributes to their positive self-concept.

FIGURE 7-2 The hospital can be frightening to a toddler. A parent’s presence is often reassuring.

Erik Erikson (in his theory on psychosocial development) defines the developmental task of the toddler age as learning autonomy versus shame or doubt. Toddlers need to be encouraged to become independent, and the caregiver should not do everything for them. The toddler who is happy and is allowed gradually increasing independence also develops a sense of security.

Lawrence Kohlberg (in his theory on moral development) believes that the toddler begins to formulate a sense of right and wrong but obeys only because the parent tells the toddler to. Moral development continues throughout childhood.

Sigmund Freud (in his theory on personality development) described the toddler as being in the “anal phase” because elimination has taken on a new meaning. The child learns in this phase to control urination and defecation.

Physical Growth

Certain physical changes foster the growth process. Weight gain slows to about 4 to 6 pounds (1.81 to 2.72 kg) per year, and height increases about 5 inches (12 cm) per year during the toddler period. Toddlers’ bodies change proportions. Legs and arms lengthen from ossification and growth in the epiphyseal areas of the long bones. The trunk and head grow more slowly. The growth of the brain decelerates. The increase in head circumference during infancy is 4 inches (10 cm). During the second year, the increase is only 1 inch (2.5 cm). Chest circumference continues to increase. Head circumference equals chest circumference at 6 months to 1 year of age. The size and strength of muscle fibers increase. Myelination of the spinal cord is practically complete by 2 years of age, allowing for control of anal and urethral sphincters. Respirations are still mainly abdominal but shift to thoracic as the child approaches school age. The stomach capacity increases to the point where the child can eat three meals a day. Appetite decreases, but it remains important that the toddler get adequate intake of all nutrients. (Nutrition is discussed later in this chapter.)

The toddler is more capable of maintaining a stable body temperature than is the infant. The shivering process in which the capillaries constrict or dilate in response to body temperature has matured. The skin becomes tough as the epidermis and dermis bond more tightly, protecting the child from fluid loss, infection, and irritation. The defense mechanisms of the skin and blood, particularly phagocytosis, are working more effectively than during infancy. The lymphatic tissues of the adenoids and tonsils enlarge during this period. Eruption of deciduous teeth continues. By 3 years of age, all 20 deciduous teeth are generally present (see Chapter 6).

The senses of toddlers do not function independently of one another or of their motor abilities. Two-year-old toddlers reach, grasp, inspect, smell, taste, and study objects with their eyes. Their attention becomes centered on those characteristics of their surroundings that capture their interest. They can correlate sight with sound, as in the ringing of a bell. Binocular vision is well-established by 15 months of age. By 2 years of age, visual acuity is about 20/40. Memory strengthens; toddlers can compare present events with stored knowledge. They assimilate information through trial-and-error plus repetition. They try alternative methods of accomplishing a goal. Thought processes advance, preparing the way for more complex mental operations. Language development parallels cognitive growth. The increase in the level of comprehension is particularly striking and exceeds their verbalization. (Language development is discussed later in this chapter.)

Guidance and Discipline

Toddlers’ emotions fluctuate greatly. They show ambivalence. They love one minute and hate the next. They cry, kick, and slap when they decide to play outdoors longer than the parent wants and then turn around and kiss that same parent for giving them a drink of water. It may be difficult for parents to understand these mood swings. Toddlers are usually trying to assert their independence. It may be best to ignore this behavior as long as children are not hurting themselves or someone else. After the tantrum, parents should divert toddlers to some pleasant activity. Table 7-2 summarizes behavior problems that may occur during early childhood, causes of those problems, and parenting tips for correcting the problems.

Table 7-2

Behavior Problems of Toddlers

BEHAVIOR	CAUSES	PARENTING TIPS FOR CORRECTING BEHAVIOR
Biting	Teeth are established. Child wants attention; child is angry.	Establish “no biting” rule. Firmly tell child “no” while looking straight in the eye. Suggest alternative safe behavior. Put child in time out. Never bite your child for biting someone else.
Bedtime resistance or refusal	Child does not want to go to bed or stay in his or her bedroom; child has already established history of being allowed to sleep with parent.	A child should stay in his or her own bed at night; explain rules for this. Establish a pleasant bedtime routine. Escort child back to bed.
Physical fighting and spitting	Children fight when angry or jealous. They see other children or people on television act this way.	Establish “no hitting” rule because it does not solve problems. Teach children “Spitting doesn’t look nice.” Tell child to handle with words; ignore bullies. Use time out. Never hit your child for hitting someone else. Praise friendly behavior.
Nightmares	Relate to developmental challenges (toddlers fear separation from parents).	Reassure and cuddle child. Provide night light, leave door open. Talk about the dream during the day. Avoid frightening movies or television programs (applies more to older children).
Night terrors	These inherited disorders involve dreams during deep sleep from which it is difficult to awaken.	Sleep deprivation may contribute to these; have child take afternoon nap or at least “quiet time.” Comfort and reassure child during night terror.
Temper tantrums	Child is angry (may be precipitated by wanting something but not getting it).	Ignore child but monitor safety. Take child to his or her room for 2 to 5 min. Avoid spanking (conveys you are out of control).
Sibling quarrels	Occurs because of nature of being siblings. Quarrel over possessions, and so on. Want to gain parents’ attention.	Encourage them to settle their own arguments; if children come to you, keep an open mind when resolving and avoid getting in the middle. Intervene if argument gets too loud. Do not permit hitting. Avoid showing favoritism. Praise cooperative behavior.

One of the objectives in the management of toddlers is to help them establish limits for themselves and to find socially acceptable outlets for their behavior. Parents who direct all their child’s activities cannot expect the toddler to develop self-confidence or autonomy.

Rituals play an important part in toddlers’ ability to achieve independence. They provide them with known routines and people and places to come back to for support and security. Children’s rituals (as at bedtime) should be incorporated into the hospital routine.

Communication

Whenever possible, children should be given choices: “Would you like to take your medicine from a medicine cup or from the syringe?” or “Would you like Mommy to put the medicine in your mouth?” Never say, “Do you want to take your medicine?” If the child replies “no,” the nurse has created a communication block.

Toddlers need a certain amount of discipline. They get into many situations that are “over their head.” When adults make a firm decision for them, the problem is at least for the time being resolved. Children feel secure because parents have helped them escape from their own primitive natures. There is controversy concerning spanking children. A time-out period is effective (Figure 7-3). The general rule is 1 minute per year of the child’s age, up to 5 minutes. Time out can change almost any disruptive childhood behavior and is most effective if the child is older than 2 years of age.

FIGURE 7-3 Time outs are a disciplinary measure used to remove the child from an activity and allow him or her to calm down and consider what was wrong in his or her actions.

Children, like adults, seek approval. Time-in refers to the positive interactions and feedback children receive when they are not misbehaving. Teach parents to catch their children being good! Providing this approval is effective and helps increase their self-confidence. Take the positive approach as much as you can. Assume that the toddler is going to be good rather than bad. For instance, “Thank you, Johnny, for giving me the matches,” will make the matches arrive in your hand more quickly than saying in a threatening tone, “Give me those matches right now.”

Positive parenting steps also include spending time alone with the toddler, praising the toddler for good behavior (“You were such a good boy to help put your toys away”), and making the child feel safe and secure through discipline and love.

Nursing Brief

Caregivers need to provide safe areas for the toddler to explore. They need to watch carefully before saying no.

Communication

Language Development

At about the end of the first year, the baby has begun vocalizing words such as “bye-bye,” “ma-ma,” and “da-da.” When toddlers see a happy response to these sounds, they repeat them. This is true throughout the toddler period. For small children to want to learn to talk, they must have an appreciative audience. At first, children refer to animals by the sounds the animals make. For example, before saying “dog,” toddlers repeat “bow-wow.” Soon they can say short phrases, such as “daddy gone car.” The 2-year-old can speak in simple two-word noun-verb sentences. Three-year-olds generally speak in three-word sentences, and so on. Toddlers respond also to tone of voice and facial expression. If an adult sounds threatening, toddlers may answer “no” and then “no” again in a louder voice. Toddlers also use “no” to express their developing autonomy. It is good to remember that toddlers who talk remarkably well and understand more than they say still cannot comprehend much of adult conversation. Sometimes when adults forget this, they scold the child merely for being too young to understand what is requested of them. Imagine yourself being punished in a foreign country because you are unable to speak or understand the language well enough to defend yourself. Adults who show empathy to small children can help minimize their frustrations. A guideline for vocalization appears in Table 7-1.

Toddlers who have just learned to walk may practically give up repeating words because they are so overjoyed at being able to get about independently. As soon as their initial fascination becomes less pronounced, they take up speech again. Delayed speech does not necessarily indicate that a child is mentally slow. The temperament and personality of the child and the family play an important role. No two toddlers have the same vocabulary at the same age; however, generalities are found in language development. If a parent is concerned about a child’s delayed speech, it can be discussed with the pediatrician during one of the child’s routine physical examinations. This allows the concern to be evaluated in light of the child’s total physical growth and development. Late talkers may be perfectly normal children who prefer listening to active participation.

Developmental norms in the use of language have been established. One widely used tool is the Denver II (see Appendix D), a revision of the Denver Developmental Screening Test (DDST). This test is used to assess the developmental status of children during their first 6 years. It evaluates according to four categories: personal-social, fine-motor–adaptive, language, and gross-motor. It is neither an intelligence test nor a neurologic test. A low score merely indicates a need for further evaluation. The test is designed for both professionals and paraprofessionals to use, and because it is a standardized test, proper administration and interpretation are crucial. Specific instructions for administering the test, scoring of the results, and a further description of the test are included in a manual that may be purchased from the publisher.

Communicating with Toddlers

Adults must keep their everyday conversation with small children simple. Offering them too many choices confuses them. When talking to a toddler, adults should position themselves so that they are at eye level with the child. In this way, adults seem less overwhelming. This is of particular importance when the child is in a fear-provoking environment such as the hospital.

Adults should also use the “I message” when communicating with a child. Saying “I feel angry when you hit your sister” does not blame or criticize in the way that “You are a bad boy to hit your sister” does. “Bad” also demoralizes the child and makes him or her feel guilty. This can leave a lasting impression.

Health Promotion and Maintenance

Daily Care

Toddlers need proper nutrition, plenty of fresh air and exercise, and sufficient rest. They also need structure and routine. By the time a child is a toddler, the mother has usually found it easier to give the bath in the evening rather than in midmorning. A flexible schedule organized around the needs of the entire household is best. This routine, however, can vary during the summer months because outdoor water play may make a tub bath optional. Parents may need to be reminded to never leave a toddler alone in the bathtub because at this age drowning and burns from hot water are still a concern.

The clothing of toddlers should be simple and easy for them to put on and take off. Pants with elastic waists are convenient for them to pull down when they go to the toilet. All clothing must be fairly loose to provide freedom of movement for jumping and other strenuous activities. Children should wear shoes with flexible soles. Tennis shoes are good choices once children are walking well. Shoes should fit the shape of the foot and be inch longer than the big toe. The heels must fit securely. Children should wear their usual shoes at their periodic checkups because these show how the shoes have been worn, which indicates to the doctor how the children are using their bodies. Parents need to check the fit every few months because shoe size changes frequently as toddlers grow.

In the summer months, children may sunburn quickly and should be protected by sunglasses that are 99% UV protection, and by clothing/sunscreen so as to prevent future skin damage. Sunscreen should be applied at least 30 minutes before going outside and be reapplied every 2 hours. Sunscreen should be used even on cloudy days. The SPF (sun protection factor) should be at least 15, and the UV protection should be “broad-spectrum” (American Academy of Pediatrics, 2010).

Sleep needs gradually decrease as children grow older. For example, they may enter toddlerhood sleeping 12 hours a night with 2 daytime naps. By the time they reach the preschool years, this amount may decrease to 8 hours of sleep at night and 1 nap. Establishing a routine for bedtime and naptime is also helpful advice. Parents may need advice on how to get the child out of the crib and into a regular bed. During the adjustment period, be sure there is a railing or chair placed next to the bed at night. The toddler’s mattress should be firm.

Adapt the toddler’s environment accordingly. The chair and play table should be adjusted to their size (Figure 7-4). In some cases, this can be easily accomplished by placing a few magazines in the seat of the chair. A sturdy, small stool placed in the bathroom allows a toddler to stand at the proper height for brushing the teeth. These simple actions help to promote independence.