Care of the TODDLER

LEARNING OBJECTIVES:

On completion of this unit, you are

expected to demonstrate understanding
of the concepts related to the care of a
family with a toddler.

Specifically, you are able to:

1. Describe the normal growth and

development of a toddler and
associated parental concerns.

2. Distinguish each milestone achieved

by the toddler and its implication.

3. Use critical thinking to analyze

methods of a family-centered care of
a toddler.
 GROWTH & DEVELOPMENT OF A TODDLER

LESSON 9

LEARNING OBJECTIVES

On completion of this lesson, you are expected to demonstrate understanding of the

concepts related to the care of a family with a toddler. Specifically, students are able to:

1. Identify key terms that are significant in the care of a toddler and the family.
2. Discuss the toddler’s biologic-proportional changes and their implications.
3. Evaluate the relationship among the motor, language, psychosocial, cognitive and
temperament milestones of a toddler.

INTRODUCTION

Soon after a child’s first birthday, important and sometimes dramatic changes take
place. Physical growth slows considerably; mobility and communication skills improve
rapidly; and a determined, often stubborn little person begins to create a new set of
challenges for the caregivers. “No” and “want” are favorite words. Temper tantrums appear.

During this transition from infancy to early childhood, the child learns many new physical
and social skills. With additional teeth and better motor skills, the toddler’s self-feeding
abilities improve and include the addition of a new assortment of foods. Left unsupervised,
the toddler also may taste many nonfood items that may be harmful, even fatal.

This transition is a time of unpredictability: one moment, the toddler insists on “me do it”;
the next moment, the child reverts to dependence on the mother or other caregiver. While
seeking to assert independence and achieve autonomy, the toddler develops a fear of
separation. The toddler’s curiosity about the world increases, as does his or her ability to
explore. Family caregivers soon discover that this exploration can wreak havoc on orderly
routine and a well-kept house and that the toddler requires close supervision to prevent
injury to self or objects in the environment . The toddler justly earns the title of “explorer.”
 CONCEPT DISCUSSION

T Tantrums, Toilet Training

E Endless Negativism

M Manifests Independence

P Physiologic Anorexia-à picky eater, pot belly

E Extreme Fear of Separation (Separation Anxiety)

R Ritualism, Regression
EXPECTED GROWTH AND DEVELOPMENT
Biologic/ Physical Development

AGE MILESTONE

12 months Birth weight triples

Birth length increases by 50%
Equal head and chest circumference
Teeth: upper and lower lateral incisors; total of six to eight
Each year the toddler gains 5 to 10 lb (2.26 to 4.53 kg) and about 3
inches (7.62 cm).

15 months Growth rate begins to decrease

Weight 24 lb (11 kg)
Height: 31 inches (74.7 cm)
Capacity of urinary bladder increases

18 months Growth decreases

Appetite lessens (physiologic anorexia)
Anterior fontanel closes
Abdomen protrudes (larger than chest circumference)
Canine teeth begin to erupt, followed by molars at around 20 months

2 years Weight: about 26-28 lb (11-12 kg)

Height: about 32-33 inches (80-82 cm)

30 months Full set of 20 temporary teeth

Dental care should begin between 1 and 2 years of age
Decreased need for naps
Gross and Fine Motor Development

AGE MILESTONE

15 months Walks alone with wide-based gait; creeps up stairs

Builds tower of two blocks; throws objects and picks them up
Drinks from cup with spillage; uses spoon clumsily

18 months Runs clumsily; climbs stairs or up on furniture

Imitates strokes in drawing
Drinks from cup; manages spoon
Builds tower of three to four cubes

2 years Gross motor skills refined

Walks up and down stairs, one step at a time, holding onto rail
Builds tower of six to seven cubes; uses cubes to form a train

30 months Walks on tiptoe; stands on one foot momentarily

Builds tower of eight blocks
Copies horizontal or vertical line
May attend to won toilet needs during day
May begin to hold crayons with fingers rather than fists
Begins to start to color within the lines of a picture
Sensory Development

AGE MILESTONE

2 years Develops eye accommodation

Visual Acuity 20/40

Vocalization and Language Development

AGE MILESTONE

15 months Four—to six-word vocabulary

States name
Says “No” even while complying with request

18 Months 10– or more word vocabulary

2 years Vocabulary: about 300 words

Uses two– or three-word phrases
Uses pronouns
Obeys simple commands
Makes simple choices when possible
DEVELOPMENTAL THEORIES

STAGES/ MILESTONE
AGES
Psychosocial Development Theory: Sense of Autonomy

18 months to 3 • Asserting independence, sometimes forcefully; parents should

years understand this is not willful misbehaving; punishment will
confuse child
• Important for caregiver to balance opportunities to explore,
offer encouraging environment in which failure is acceptable
and not something to constantly avoid.

Cognitive Development Theory

13 to 18 months • Actively experiments to achieve new goals
Tertiary Circular • Increased Object permanence
Reactions • Distinguishes object from self
• Early memory
• Relationships: spatial, causal, temporal
• Can enter a sequence in progress

19 to 24 months • Unlimited object permanence awareness

Invention of new • Infers cause while effect is occurring
means through • More symbolic mimicry
mental • Time understood through anticipation, memory, and being able
combinations to wait
• Egocentric thought and action (unable to understand others’
perspectives)
• Global organization (belief that one part’s change changes the
whole– related to a desire for ritualism so nothing is out of
sequence or out of order)

2 to 4 years • Language used as mental symbolizing

• Increased sense of time, space, causality but poor concept of
passing of time
SOCIAL DEVELOPMENT

STAGES/ MILESTONE
AGES
15 months • Says “No” even while complying with request

18 months • New awareness of strangers; separation anxiety

• Begins to have temper tantrums
• Ritualistic; has favorite toy or blanket
• Thumb sucking most prominent

2 years • Shows signs of increasing autonomy and individuality

• Makes simple choices when possible
• Remains ritualistic, especially at bedtime
• Can help undress self and pull on simple clothes
• Doesn’t share well
• Caregiver/ parent can help child learn boundaries by
teaching them to accept appropriate limits

30 months • Beginning to see self as separate individual from reflected

appraisal of significant others
• Sees other children as objects
• Becomes increasingly independent, ritualistic and
negativistic
• Need for autonomy; respond well to choices not requiring a
“yes” or “no”
 ASSIGNMENT 9.1

T Tantrums, Toilet Training

E Endless Negativism

M Manifests Independence

P Physiologic Anorexia-à picky eater, pot belly

E Extreme Fear of Separation (Separation Anxiety)

R Ritualism, Regression

INSTRUCTION: Create one (1) learning ACRONYM/ ABBREVIATION related to the concepts
discussed about the CARE OF A FAMILY WITH TODDLER, similar on the above presentation.
Make use of the terminology TODDLER or other terminologies related to the lesson.
File Format upon submission: Last Name_Assign 9.1
 FEEDBACK

Let us look into how well you fared. Compare your answers with the
answer key posted in the Learning Management System. If you an-
swered all questions correctly, congratulations! It shows that you
are already familiar with the topics discussed in lesson 9. If your an-
swers are quite not close to the discussion, you have some ideas
about the topics covered but need to learn more.
Now, you have a glimpse of the Growth and Development of a
Toddler. Read on and continue exploring this topic.
Read further on your textbook pages _______ to _________.

Quiz 9.1

Congratulations! You are done with Lesson 9. In order to see how much you have learned, an
online quiz has been prepared for you to answer. Follow the steps stated herewith.
1. Log in to your NDMU Academic Learning Management System Account.
2. Go to My Courses and click NCM 107 A.
3. Look for the online quiz prepared under Week 10 entitled Growth & Development of a
Toddler.
4. The quiz is open for answering on _____(date)______, between ____ AM to ____ AM.
5. Your are expected to finish the quiz within the time set in the system.
6. Only 1 attempt is allowed unless reasons such as poor internet connection would have
affected your access to the quiz.

Best of luck and well done!

 WELLNESS PROMOTION & INJURY PREVENTION
FOR THE TODDLER AND FAMILY

LESSON 10

LEARNING OBJECTIVES

On completion of this lesson, you are expected to demonstrate understanding of the

concepts related to coping with toddler concerns, wellness promotion and injury prevention.
Specifically, students are able to:

1. Discuss various parental concerns related to a toddler’s growth and development such
as Toilet training, feeding, play and socialization.
2. Manage parental concerns related to toddler’s growth and development through
formulation of health teachings suited for each concern.
3. Recognize important safety issues for the toddler.
4. Formulate interventions and health teachings for the prevention of injury.

INTRODUCTION

Toddlerhood can be a difficult time for family caregivers. Just as parents are beginning
to feel confident in their ability to care for and understand their infant, the toddler changes
into a walking, talking person whose attitudes and behaviors disrupt the entire family.
Accident-proofing, safety measures, and firm but gentle discipline are the primary tasks
for caregivers of toddlers. Learning to discipline with patience and understanding is difficult
but eventually rewarding. At the end of the toddlerhood stage, the child’s behavior generally
becomes more acceptable and predictable.
Erikson’s psychosocial developmental task for this age group is autonomy
(independence) while overcoming doubt and shame. In contrast to the infant’s task of build-
ing trust, the toddler seeks independence, wavers between dependence and freedom, and
gains self-awareness. This behavior is so common that the stage is commonly referred to
as the “terrible twos,” but it is just as often referred to as the “terrific twos” because of the
toddler’s exciting language development, the exuberance with which he or she greets the
world, and a newfound sense of accomplishment. Both aspects of being 2 years old are
essential to the child’s development, and caregivers must learn how to manage the
fast-paced switching between anxiety and enthusiasm
TODDLER CARE CONCERNS

A. TODDLER NUTRITION
• Nutritional Objectives
 Adequate nutrient intake to meet continuing growth and development needs
 Consumption of fresh, rather than processed foods (fruits, vegetables)
 Psychosocial development in relation to food patterns, eating behavior, attitudes

• Diet
 Reflects patterns and preferences of culture, parents and siblings
 Calorie and nutrient requirements increase with age, despite slower growth
 Increased variety in types and textures of food; provision of choices to address
growing independence
 Increased involvement in feeding process; stimulation of curiosity about food
environment; language learning
 Consideration for appetite, choices, motor skills

• Eating/ Drinking Behavior

 Prefers finger foods
 Prefers sweet drinks; juices should be limited to 4 oz (120 mL) or less per day to
prevent dental caries
 TV commercials influence selection

• Nutrition Problems
 Obesity or underweight: increased or decreased caloric intake; need for nutritional
counseling
 Low intake of calcium, iron, vitamins A and C may need supplementation
 Mealtime struggles related to increased autonomy and parental attitudes toward food

AGE FEEDING MILESTONES

18 months • Balanced diet of table food vegetables, fruits and whole grains
recommended
• Toddlers become “picky” or “fussy” eaters with preferences and
amount consumed varying widely
• Colorful finger foods preferred
• Ritualism: preference for same dish, cup, or spoon; preferences
and amount consumed varying widely
• May have rules about food touching, etc.
B. TOILET TRAINING
• Most important integrative task for toddler
• an individualized task for each child. It should begin and be completed according to a
child’s ability to accomplish it, not according to a set schedule
 Approach and attitude of parents play the most vital role

Physical Maturation: must be reached before training is possible

 Sphincter control: adequate when child can walk
 Urine retention: at least 2 hours
 Demonstration of readiness: 18-24 months
 Usual age for bowel training: 22 to 30 months
 Daytime bowel and bladder control: usually after 2 years of age
 Night control: usually several months to years after achievement of daytime control
***Night wetting to 6 years of age: Investigate cause (usually physical)

Psychologic Readiness
 Aware of act of elimination
 Able to inform caregiver of need to urinate or defecate
 Desire to please parents

Process of Training
 Usually begins with bowel then bladder
 Potty chair helpful so feet touch floor
 Intermittent periods of urination and fecal soiling
 Regression when there is stress (eg, new sibling)

Parental Response
 Choose specific word for act
 Have specific time and place for elimination
 Treat occasional accidents in matter-of-fact manner
 Avoid punishing

C. DENTAL CARE
• Encourage parents to offer fruit (bananas, pieces of apple, orange slices) or protein
foods (cheese or pieces of chicken) rather than high carbohydrate items for snacks
• Calcium (found in large amounts in milk, cheese, and yogurt) is especially important to
the development of strong teeth and are good for snacks.
• For tooth care, toddlers need to have a toothbrush they recognize as their own.
• Toward the end of the toddler period, they can begin to do the brushing themselves
under supervision (almost all children need some supervision until about age 8).
• Urge parents to schedule a first visit to a dentist skilled in pediatric dental care at
about 12 months of age for assessment of dentition
D. BEHAVIOR

RITUALISM
• They will use only “their” spoon at mealtime, only “their” washcloth at bath time
• The child who seems to need an excessive number of objects to cling to or an
excessive number of routines, however, may be trying to say, “I need more guidelines,
more rules. Don’t let me be quite so independent.”

NEGATIVISM
• As part of establishing their identities as separate individuals, toddlers typically go
through a period of extreme negativism.
• They do not want to do anything a parent wants them to do. Their reply to every request
is a very definite “no.”
• A toddler’s “no” can best be eliminated by limiting the number of questions asked of the
child.
• Making a statement instead of asking a question can avoid a great many negative re-
sponses.
• a parent could give a secondary choice

SEPARATION ANXIETY
• Most toddlers react best to separation if a regular babysitter is employed or the day care
center is one with consistent caregivers.
• Many are more comfortable if they are cared for in their own home.
• It helps if they have fair warning that they will have
• It helps if parents say goodbye firmly, repeat the explanation they will be there when
the child wakes in the morning, and then leave.
***avoid prolonged goodbyes
***avoid sneaking out as it can strengthen fear of abandonment

TEMPER TANTRUMS
• Temper tantrums occur as a natural consequence of toddlers’ development
• They occur because toddlers are independent enough to know what they want, but they
do not have the vocabulary or the wisdom to express their feelings in a more socially
acceptable way.
• the best approach is for parents to tell a child simply that they disapprove of the tantrum
and then ignore it.
• Parents should then accept the child warmly and proceed as if the tantrum had not oc-
curred. This same approach works well for nurses caring for hospitalized toddlers.
DISCIPLINE
• Remind parents that “discipline” and “punishment” are not interchangeable terms.
• Discipline means setting rules or road signs so children know what is expected of them.
• Punishment is a consequence that results from a breakdown in discipline, from the
child’s disregard of the rules that were learned.
• Enforce limits which must be a day-to-day interaction with the child
• 2 general rules to follow:
(a) parents need to be consistent and
(b) rules are learned best if correct behavior is praised rather than wrong behavior
punished.
• “Timeout”- a technique to help children learn that actions have consequences.
• Effective use of “timeout”:
1. parents first need to be certain their child understands the rule they are trying to
enforce.
2. Parents should give one warning.
3. If the child repeats the behavior, parents select an area that is nonstimulating, such
as a corner of a room or a hallway.
4. The child is directed to go immediately to the “timeout” space. The child then sits
there for a specified period of time.
5. If the child cries or shows any other disruptive behavior, the timeout period does not
begin until there is quiet.
6. When the specified time period has passed, the child can return to the family.
7. A guide regarding how long children should remain in their “timeout” chair is 1
minute per year of age. Using a timer that rings when time is up lets children know
when they can return to the family.
E. PLAY
Parallel Play: playing alongside, not with, other children; less emphasis on exploration
using senses; imitation is distinguishing characteristic

Play of Toddlers
 Mostly free and spontaneous, no rules
 Short attention span, requires frequent change of toys
 Dangers associated with toys
* Breaks toy through exploration and ingests small pieces
* Ingests lead from lead based paint on toys
* Is potentially burned by flammable toys
 Imitation and make-believe play begins by age 3 years
 Suggested toys
*Play furniture, dishes, cooking utensils, telephone
*Puzzles with few large pieces
*pedal-propelled (eg, tricycle), straddle (eg, rocking horse)
*Pounding, push-pull, blocks
*Clay, crayons, finger paints

F. PROMOTING SAFETY

• Accidental ingestions (poisoning) are the type of accidents that occurs most frequently in
toddlers.
• Aspiration or ingestion of small objects such as watch or hearing aid batteries, pencil
erasers, or crayons is also a major danger for children of this age
• Urge parents to childproof their home by putting all poisonous products, drugs, and small
objects out of reach by the time their child is crawling, and certainly by the time their
child is walking
• Other accidents that occur frequently in toddlers include motor vehicle accidents, burns,
falls, drowning, and playground injuries.
• To prevent serious injury, a toddler must be supervised at all times.
• Until children weigh 40 to 60 lb, they need a toddler-size car seat for safety in
automobiles
• They need to wear a helmet as soon as they begin riding a tricycle.
• A safety gate on the door of the room is another way to keep a toddler contained and
safe.
• Lead Screening
***lead ingestion of it leads to serious damage in the brain and nervous system,
kidneys, and red blood cells.
***Low Levels: cause learning and behavioral problems (Keefe, 2007).
***High levels: may result in seizures, cognitive challenges, coma, and even death.
 EXERCISE 9.1

PRACTICE QUESTIONS: Answer the following questions by encircling the letter of your
chosen answer.

1. The nurse is weighing a toddler who is 3 years old. If this child has had a typical pattern of
growth and weighed 18 pounds at the age of 1 year, the nurse would expect this toddler to
weigh approximately how many pounds?
a. 22 pounds c. 36 pounds
b. 30 pounds d. 42 pounds

2. The nurse is observing a group of 2-year-old children. Which of the following actions by the
toddlers would indicate a gross motor skill seen in children this age?
a. Turns pages of a book
b. Uses words to explain an object
c. Drinks from a cup
d. Runs with little falling

3. A major developmental milestone of a toddler is the achievement of autonomy. What should

the nurse instruct the parents to do to enhance their toddler’s need for autonomy?
a. Teach the child to share with others.
b. Help the child to learn society’s roles.
c. Teach the child to accept external limits.
d. Help the child to develop internal controls.

4. A nurse on the pediatric unit is observing the developmental skills of several 2-year-old
children in the playroom. Which child should the nurse continue to evaluate?
a. cannot stand on 1 foot
b. builds a tower of 7 blocks
c. uses echolalia when speaking
d. colors outside the lines of a picture

5. A nurse is evaluating a 3-year-old’s developmental progress. Which task would indicate

developmental delay if not performed by the child?
a. Copying a square
b. Hopping on one foot
c. Catching a ball reliably
d. Using a spoon effectively
 EXERCISE 9.1

6. The toddler-age child engages in “parallel play.” The nurse observes the following behaviors
in a room where children are playing with dolls and stuffed animals. Which of the following is
an example of parallel play? Two children are
a. sharing stuffed animals with each other.
b. sitting next each other, each playing with her or his own doll.
c. taking turns playing with the same stuffed animal.
d. feeding the first doll, then feeding the second doll.

7. In preparing snacks for a 15-month-old toddler, which of the following would be the best
choice for this age child?
a. Small cup of yogurt c. Handful of dry cereal
b. Five or six green grapes d. Three or four cookies

8. The nurse is working with a group of caregivers of toddlers. The nurse explains that accident
prevention and safety are very important when working with children. Which of the following
statements is true regarding accidents and safety for the toddler? Select all that apply.
a. Child car restraints are required for children.
b. Accidents are the leading cause of death in children up to age 4 years.
c. At least 5 to 6 inches of water is necessary for drowning to occur.
d. Touching and tasting substances in the environment is a concern.
e. Poisonous items should be kept in a locked area.
f. Child-resistant packaging keeps children from opening any bottle.

9. A nurse plans to talk to the parents of a toddler about toilet training. What should the nurse
explain is the most important factor in the process of toilet training?
a. Parents’ attitude about it
b. Child’s desire to remain dry
c. Child’s ability to sit still on the toilet.
d. Parents’ willingness to work at the toilet training

10. A parent tells a nurse at the clinic, “Each morning I offer my 24-month-old child juice, and
all I hear is ’No’. What should I do because I know my child needs fluid?” What strategy
should the nurse suggest?
a. Offer the child a choice of two juices.
b. Distract the child with a favorite food.
c. Offer the child the glass in a firm manner.
d. Allow the child to see the parent getting angry.
 ACTIVITY 10.1

CRITICAL THINKING: What Would You Do? Below are situations related to the Care of A
Family with Toddlers . Choose one (1) among the three (3) scenarios and answer the questions
on the chosen situation a comic strip. Outputs for this activity may either be digitally created or a
freehand drawing of the comic strip bearing the answers for the questions in the scenarios. It
must be submitted through Schoology following this Filename Format: Group #_Activity 10.1.
1. Nurse Sarah is working as school nurse. One parent approached her and asked for advise
on a particular scenario she had encountered with her daughter.
Scenario: In the supermarket, her 2-year old daughter, Lauren is having a loud, screaming
temper tantrum because she won’t buy her some expensive cookies. As she is trying to talk
with her, she is yelling, “No, I want them.”
a. What are the reasons toddlers have temper tantrums?
b. What is the best way to respond to a toddler who is having a temper tantrum? Why?
c. What would the mother say to Lauren in this situation?
d. What actions would the mother take during the temper tantrum? After the temper tan-
trum?
2. Marti is an administrative personnel in the hospital where Joshua, a pediatric nurse, works.
He complains to Nurse Joshua that his 2-year-old daughter Tasha is very difficult to put to
bed at night. Marti often just gives up and lets Tasha fall asleep in front of the television.
a. What are some of the factors that might be affecting Tasha at bedtime?
b. What would you explain to Marti regarding bedtime rituals and routines for toddlers?
c. What would you suggest Marti do with Tasha at her bedtime?
3. Jed is a 26-month-old child whose family caregivers work outside the home. He goes to a
day care center 3 days a week and is kept by his grandmother the other 2 days. Jed’s mother
asks you for advice in toilet training Jed.
a. What questions would you ask Jed’s mother regarding his physical readiness for toilet
training?
b. What suggestions will you offer regarding bowel training? Bladder training?
c. How might the variety of caregivers Jed has affect his toilet training?
d. What could Jed’s mother do to provide consistency in toilet training for her child?
 FEEDBACK
Let us look into how well you fared. Compare your answers with the
answer key posted in the Learning Management System. If you an-
swered all questions correctly, congratulations! It shows that you are
already familiar with the topics discussed in lesson 10. If your an-
swers are quite not close to the discussion, you have some ideas
about the topics covered but need to learn more.
Now, you have a glimpse of the Wellness Promotion and Injury
Prevention for Toddlers and their family. Read on and continue
exploring this topic.
Read further on your textbook pages _______ to _________.

Quiz 10.1

Congratulations! You are done with Lesson 10. In order to see how much you have learned,
an online quiz has been prepared for you to answer. Follow the steps stated herewith.
1. Log in to your NDMU Academic Learning Management System Account.
2. Go to My Courses and click NCM 107 A.
3. Look for the online quiz prepared under Week 11 entitled Wellness Promotion and Injury
Prevention for toddlers.
4. The quiz is open for answering on _____(date)______, between ____ AM to ____ AM.
5. Your are expected to finish the quiz within the time set in the system.
6. Only 1 attempt is allowed unless reasons such as poor internet connection would have
affected your access to the quiz.

Best of luck and well done!